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WELL/PUMP PERMIT SAN Jr':,QUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPI ES 1 YEAR FROM DATE ISSUED JOB ADDRESS U , 0/J et o 0 CITY/ZIP 1" tf -fC-A / m m Y's /t t " D CROSS STREETO- J' /N+/�S ,Iyd^1�/� A N 'J ARCEL SIZE /. 7LAND USE APPLICATION# A OWNER NAMEL b A�Q /7 //1 f� C /I ��(/YI f� PHONE OWNER ADDRESS // 'CSL Yl/ _ 'O CITY/STATE/ZIP CONTRACTOR + o h o PHONE 6 CONTRACTOR ADDRESS `J O ei �. J\ r O S� CITY/STATE/ZIP C ✓ Q SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP /� B LICENSE -57 [:1 C-61 F1 D-09 ❑ -1:21X Other NUMBER <-4? I EXPIRATION DATE I / DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) INTENDED USE ❑Domestic/Privaterrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sam pling/Characte i ❑Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK New Well E]Replacement Well ❑Well Alteration/Modification E]Other f El Monitoring Well(s) #of wells [:]Soil Boring #of borings #of ri gss) Geotechnical- s'�� ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair HEAIt/Ic?411,'d COU []New Pum ❑Pum Replacement []Pump Repair E]Raise Well CasingALT/y Nft,rF� N7]. WELL CONSTRUCTION A,4FNT Drilling Method �o<ud Rotary El Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other Proposed Well Depth Ay© ft Excavation X p'` in diameter ❑Open Bottom [oj evel Pack/Gravel Size 6 in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter 12_ in Thickness/Gauge/ASTM Sched J404e ❑Steel QPfa is ❑Stainless Steel S41 —/o Grout Seal Depth O p' ft O'N41eat Cement(94 Ib bag/5-10 gal water) and Cement le.S // , sack mix/7 gal water ❑Bentonite(20%solids) ❑Other C-rMe17k 4' Grout Placement Method L^mped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor Other E]Concrete Pedestal dimensions:Width ft Length ft Thick in ❑Christy Box []StovePip 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 C MPENSATION LAWS. MI IMUM HOU AD ANCE NOTICE REQUIRED FOR INSPECTISASE CALL (209) 953-7697 SIGNED TITLE "4t �s _ DATE C P RTMENT USE ONLY Application Accepted By Date Area _ mployee ID#h~ Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constru ell Depth ft COMMENTS l Ko I PE SC Received Chec Amount Permit/ Invoice Codes Info B Cash emitted Date Service Request# Invoice# Well ID# J 0 d- EHD 43-06 8/01/16 WELL/PUMP PERMIT