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y WELL/PUMP PERMIT .N JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 JN-REFUNDABLE PERMIT CALL`2�0I9 953-7697 FOR INSPECTIONS EXPIRES %1/YEAR FROM DATE ISSUED J'B ADDRESS 2 V D 0 F 41CA Moo F�Q 46,,fou / -/J 2-Z Q m 7 CITY/ZIP I I . / PARCEL SIZE 2-3! D CROSS STREET AP / LAND USE APPLICATION# 0 OWNER NAME PHONE �? OWNER ADDRESS CITY/STATE/ZIP bovi Of CONTRACTOR To-ow-On / Aad o. A-"Jar-,O" PHONE 211>11 -20' 7 - 7023 T')CONTRACTOR ADDRESS D h� L'5'T K'G, �✓%�y CITY/STATE/ZIP `�C I c4/q,5-2-4i,) SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 n C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE 05//�311ZDI7 DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) i Arsenic(4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial CI Water Quality Monitoring }�Soil Sampling/Characterization [I Public Water System / ` If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK El New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells Soil Boring(s) 3 #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 I Open Bottom u Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched [I Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft XNeat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) LI Other Grout Placement Method ElPumped gFree Fall Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller I-1 Pump Contractor n Other ❑ Concrete Pedestal []Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe�] PUMP ❑ Submersible El Turbine I I Other HP Pump Set 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. MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR(INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNEDWrIA , nUP" i TITLE V�J�Q� / S r DATE 7 L ILI ox ENNFIRONI A0 TA. DEP RTMENT U E NLY W11 Application Accepted By Date l Area Employee ID#_9�Q1SLL- Grout Inspection By Date 2 l 1.1 SPECIAL Well Permit Pump Inspection By Date I I WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# odes Info Cash Remitted Service Request# ^0 2 EHD 43-06 8/01/16 WELL/PUMP PERMIT