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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-34 NON-REFUNDABLE PERMIT CALL 2009) 953-7697 FOR INSPECTIONS EXPI�R♦ES/1 YEAR FROM DATE ISSUED U JOB ADDRESS VCl IlAI MI�Q IL S I CITY/ZIP Trill c-1 ( A m tw CROSS STREET, �/♦� �f� ,f� APIN2,1142-d�7j�� PARCEL SIZE O..w� LAND USE APPLICATION# OWNER NAME ('��`I`tt-e—1 1 ft-e r /J/VL��r PHONES 1 Q/ 3C�-3 30 vm�i OWNER ADDRESS �lD e-t Lo a �JITY/STATE/ZIPS ♦ Cr�A •5!/ J ' Y2Z- 112.0 CONTRACTOR Im L��`��++��11 1 . • //�� PHONEC CONTRACTOR ADDRESS v-t Wee CITY/STATE/ZIP Mod e,�l>) Cm �qR 1 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP ' / LICENSE )(C-57 ❑ C-61 ❑ D-09 Other NUMBER EXPIRATION DATE q-3&-L{ DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) 11 Dibromochloropropane (4392) Arsenic(4393) INTENDED Use Domestic/Private Irrigation/Agricultural i I Industrial ❑ Water Quality Monitoring I I Soil Sampling/Characterization U Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK New Well >11CReplacement Well I I Well Alteration/Modification ❑ Other I I Monitoring Well(s) #of wells I I Soil Boring(s) #of borings I Geotechnical #of borings I I Out-Of-Service Well I I Out-Of-Service Well Renewal ❑ Cross-Connection Repair F New Pum ❑ Pump Replacement I I Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling MethocIXiMud Rotary ❑ Air Rotary I i Auger i! Cable Tool ❑ Push Point Other Proposed Well Depth 2200 ft Excavation 12- in diameter Fi Open Bottom XGravel Pack/Gravel Size_ in diameter Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter 10 in Thickness/Gauge/ASTM Sched 2.00 ! Steel XPlastic Stainless Steel Other Grout Seal Depth 2lO0 ft 1 Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack i,!"47 aa!water Bentonite(20%solids) I I Other Grout Placement Method)(Pumped I i Free Fall I Other ! Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller yPump Contractor I I Other Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box a Stove Pipe PUMP Submersible[_] Turbine 11 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. MIN UM 48 HOUR ADVANCE NOTICE REQUIRED FOP, INSPECTIONS - PLEASE CALL (209) 953-7697 O SIGNED TITLE L01 r DATE J--'/ 7 Wr km Y 11 ni6 S Y Afj J()ACIUI j C U qn A �9 DPA13TMENT U E ONLY Application Accepted By Date Area Employee ID#� Grout Inspection By Date $PECI L Well Permit Pump Inspection By Date WAIVER Received _ rI ii Soil Boring Inspecti n By Date Corgstr cted Well Depth L I V ft COMMENTS w I _�1 �� _�I-`� �( �J I CJ- if: � Recei check#l - I "7�rAdunl Date Permit/ Invoice# Well ID# Codes nfo -By. Cash Remitted Service Request# 3% W S Is Icks C540-10 WOOL EHD 43-06 8/01/16 WELL/PUMP PERMIT