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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 1 YEAR FROM DATE ISSUED JOB ADDRESS 97&Y S I! / 1-1 10� CITY/ZIP /ROA m CROSS STREET /r✓ !�{/ioS /Ll� APN - D,O ZI—PARCEL SIZE /•!/% LAND USE APPLICATION# 0 M OWNER NAME L/ � �/L PHONE 1 Q 3J S7By OWNER ADDRESS -e v3 S CITY/STATE/ZIP CONTRACTOR /9 ;/��-77J,,��,�� PHONE ?;7Z-7-75-7 CONTRACTOR ADDRESSlO[�CSJGt LCIOl7 /�!i CITY/STATE/ZIPtZ,#� SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY//STATE//ZIP LICENSE C-57 ❑ C-61 ❑ D-09 1] Other NUMBER A 7Z)7 EXPIRATION DATE 1� "j/ ZOZ'o DOMESTIC WELL SAMPLING: i 1 General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) 1 1 Arsenic(4393) INTENDED USE ?il Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial 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 Pum ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method y Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool C] Push Point ❑ Other Proposed Well Depth ft Excavation �— in diameter ❑ Open Bottom YGravel Pack/Gravel Size 3A, in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter�, in Thickness/Gauge/ASTM Sched 5bk /7 ❑ Steel fay Plastic ❑ Stainless St I ❑ Other Grout Seal Depth 2G22 ft ❑ Neat Cement(94 lb bag/5-10 gal water) &erf ck mix/7 gal water Bentonite(20%solids) ❑ Other Grout Placemen ethod Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By � Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions:Width_y-f-ft Length y.s— ft Thick .. in ❑ Christy Box ❑ Stove Pipe PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level E 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. MINIMUM ADVANC CE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED " TITLE �� DATE Q FED 11 11-1 IU AP N R NNE TY D EIPRTM T 5 i I i i i -H EP RTMENT USE ONLY Application Accepted By ?q ! Date Area Employee ID# A~ Grout Inspection By r�A3 -1/jl)f\—" Date n SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Permit/ Codes I o B sh emitted Date Service Re uest# Invoice# Well I # EHD 43-06 8/01/16 WELL/PUMP PERMIT