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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)953-7697 FOR INSPECTIONS EXPIRES 11 YEAR FROM DATE ISSUED LP JOB ADDRESS O 1 ' CITY/ZIP '5 /1ec- _--k-)6C / - m / D L (,CSf�(� APN '� V / t'� PARCEL SIZE)55 �'L CROSS STREET T AND USE APPLICATION# A OWNER NAME �� /1 1 l' S '� -i tf P�1 S` ^1 PHONE r/? r� OWNER ADDRESS 7 r G" p �% J CITY/STATE/ZIP CONTRACTOR (/�11(1 r'-' PHONE2_ /jltq'(.n&_31 CONTRACTOR ADDRESS l� 1 C G�}oi'1 CITY/STATE/ZIP Ma()4,eec - (/2CZ SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE =1 C-57 f 61 I I D-09 I I Other d* �i- ((� NUMBER EXPIRATION DATE ��ZE 20 DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) F1 Dibromochloropropane (4392) Arsenic(4393) INTENDED USE omestic/Private I I Irrigation/Agricultural 1.1 Industrial 11 Water Quality Monitoring I I Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number r- TYPE OF WORK ❑ New Well I I Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings I I Geotechnical #&XftCEFj ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair Fb4Te_w Pump I I Pump Replacement 11 Pump Repair Raise Well Casing WELL CONSTRUCTION SAN J Drilling Method Li Mud Rotary !,I Air Rotary I I Auger I 1 Cable Tool IJ Push Point I I Other ENVIARV/N COU Proposed Well Depth ft Excavation in diameter I I Open Bottom I 1 Gravel Pack/Gravel Size Ty OERigp�rqr ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched IJ Steel ❑ Plastic LI Stainless Steel I I Other Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water i Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped `! Free Fall ❑ Other Retardant/Accelerator(name) PEDESTAL Installed By I-I Driller 0<ump Contract o Other &rCdncrete Pedestal ' Dimensions:Widt ft Length ft Thick in Christy Box I Stove Pipe PUMP 17 Submersible ' Turbine !' Other HP Pump Set ft Standing Water Level yo 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 COMPENS LAWS. MIN 48 U ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED TITLE 1216144&c DATE i A R T M E N T USE ONLY el Application Accepted By / � Date = - [1 �% Area / 'n Area Employee ID# ` = d Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By 1�'-�tiJ `V U��/ ��1"\ Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received ec Amount Date Permit/ Invoice# Well ID# Codes Info I pyn Ias Remitted Sery ice Re uest# L , G I, 1-7 EHD 43-06 8/01/16 WELL/PUMP PERMIT