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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 `NON-REFUNDABLE PERMIT /CALL 209)9953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Ln JOB ADDRESS C�/ (J 1 fJ�J CITY/ZIP m / D CROSS STREET I APN�i� —v3—PARCEL SIZE LAND USE APPLICATION# A m OWNER NAME PHONE ��/ OWNER ADDRESS W CITY/STATE/ZIP IA�Q , CONTRACTOR ( T CQ�'a7 �)"'4 D011 `w i�\ r/Z C1Vr // S LfZ�I I � �"TO 0/ U 16 CONTRACTOR ADDRESS 13 IQ ( /,�'/r V_/ S (> 1 0 CITY/STATE/ZIP 16 l c4 q 5-3 o SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE >('C-57 ❑ C-61 ❑ D-09 Li Other NUMBER EXPIRATION DATE 'r DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial I I Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation in diameter I Open Bottom I_I Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) Cl Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other I Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller Cl Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe �( PUMP Submersible❑ Turbine ❑ Other HP Pump Set /C O ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MI UM 48 HOUR AVA�NCE�NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED V' TITLE CLAW W �'Z DATE T Q / L E MN EP RTMENT USE ONLY Application Accepted By Date 16? Area Employee ID#� Grout Inspection By Date f# J SPECIAL Well Permit Pump Inspection By 'R&Ak � SOLkV6AW� Date / w, Ll WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Receivedheck Amount Date Permit/ Invoice# Well ID# Cods Info By Cash Remitted Service Request# EHD 43-06 8/01/16 WELL/PUMP PERMIT