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WELL/PUMP PERMIT P f r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D=PARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7 97 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED � m JOB ADDRESS CITYIZIP C' q!; m /(/ I/L rAPN '^ CROSS STREET O �O PARCEL SIZE /(J LAND USE APPLICATION# � P cam,, �j L ,r m OWNER NAME ��J `'� T ` 0PHONE[3 ?1 J/`�� —/ OWNER ADDRESS / / n © O CITY/STATE/ZIP Zoct ei'� -7 Q3 / CONTRACTOR � a, r, PHONE, CONTRACTOR ADDRESS 10b J 4V �n .7U CITY/STATE/ZIP SUBCONTRACTOR l! C 1" G PHONE ✓�` �� SUBCONTRACTOR ADDRESS CITY/ - JU`S S �T �yAT r�E/(ZIP LICENSE -57 F1 C-61 CI D-09 I I Other NUMBER 3 7/ EXPIRATION DATE DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial I 1 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 [7 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal 1_I Cross-Connection Repair ew Pump ❑ Pump Replacement Il Pump Repair Ci Raise Well Casing WELL CONSTRUCTION Drilling Method>AAud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool I I Push Point ❑ Other Proposed Well Depth ft Excavation _ � in diameter I I Open Bottom ravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter K in Thickness/Gauge/ASTM Sched '?— — I 1 Steel >11�lastic ❑ Stainles Steel 11Other Grout Seal Depths G ft ❑ Neat Cement(94 lb bag/5-10 gal water) }^Sand Cement ,©' sack mix/7 gal water 1-1Bentonite(20%solids) I1 Other /` Grout Placement Method' Pumped ❑ Free Fall ❑ Other 11 Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor I I Other ❑ Concrete Pedestal I IDimensions:Width 4 ft Length ft Thick I in ❑ Christy Box [1 Stove Pipe PUMP Submersible❑ Turbine ❑ 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. MINI M 24 HO R ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED +.� !tl TITLE DATE i A J A UI C.__U 77 ,DEFIARTMENT USE ONLY 4&Ac Application Accepted By Date Area Employee ID# Grout Inspection By Date j" J SPECIAL Well Permit Pump Inspection By Date 1 6 I �, LJ WAIVER Received Soil Boring Inspection By Date_ Cunstructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Permit/ Cod Info B Cash emitted Date Service Request# Invoice# Well ID# i toPvc 44 EHD 43-06 8/01/16 WELL/PUMP PERMIT