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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 PERMI CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM QATE ISSUED JOB ADDRESS CITY/ZIP m �/� i CROSS STREET AP �7� L/ �! PARCEL SIZE .�ND USE APPLICATION# 0 /7{ m OWNER NAME HON ✓ J y OWNER ADDRESS CITY/STATE/ZIP V CONTRACTOR ya); PHONE 3 CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR 4 PHONE SUBCONTRACT ADDRESS /STATE/ZIP 'i L'U tft LICENSE -57 U C-61 I I D-09 11 Other NUMBE EXPIRATION DATE DOMESTI WELL SAMPLING: 11 General Mineral/Coliform Bacteria (4391)❑ Dibromochloropropane (4392)11 Arsenic(4393) INTENDED USE 1-I Domestic/Private Irrigation/Agricultural s Industrial ❑ Water Quality Monitoring I I Soil Sampling/Characterization I I Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK 1 I New Well I I Replacement Well ❑ Well Alteration/Modification I I Other I I Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings I I Geotechnical #of borings I Out-Of-Service Well I I Out-Of-Service Well Renewal 1 Cross-Connection Repair I New Pump XPump Replacement I I Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method I_I Mud Rotary I I Air Rotary I 1 Auger I I Cable Tool ❑ Push Point CI Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom s Gravel Pack/Gravel Size in diameter o Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic [I Stainless Steel I I Other Grout Seal Depth ft I l Neat Cement(94 lb bag/5-10 gal water) 1.1 Sand Cement sack mix/7 gal water I I Bentonite(20%solids) I I Other Grout Placement Method I I Pumped I I Free Fall 1.1 Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By I I Driller I! Pump Contractor CI Other I I Concrete Pedestal I]Dimensions:Width ft Length ft Thick in 11 Christy Box I 1 Stove Pipe PUMP Submersibles Turbine I I Other HP==ILL Pump Set ft Standing Water Level ft I HEREBY CE TI Y 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 WORKERP OMPENSATION LAWS. M 48 A NCE N TICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 5 -769 SIGNED TITLE DATE 'ScIMT q )IV rL N ,D7VPAqfTMENT USE NLY Application Accepted By Date Area `Z Employee ID# Grout Inspection By Date I I SPECIAL Well Permit Pump Inspection By Date �� b�2�l� I I WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE Sc Received aO.V Amount Date Permit/ Invoice# Well ID# Codes Info ---Casn Remitted Service Re uest# jj I (Gl EHD 43-06 8101116 WELL/PUMP PERMIT