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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 PERMIT r�(� CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED yo JOB ADDRESS I��V 1 t ) CITY/ZIP LWAJ "7t-S-3�2_& N m q —� q 4- S c 2 n CROSS STREET A l L��1 APN PARCEL SIZE LAND USE APPLICATION# S OWNER NAME a�per'' loll C` t(LL '�PH/ONCE �) [� CD OWNER ADDRESS 10-71132 VON 4LN4't CITY/STATE/ZIP L' ✓`?ifTf�o `TTi q5�?y CONTRACTOR i nL��L(el I GrT�CC-_LLA W/��= PHONE` �^ �J'� CONTRACTOR ADDRESS �7 I �J : ��I 1 CITY/STATE/ZIP H L/�/�Jlv1 .✓} "�j A( 22 SUBCONTRACTOR PHONE (,_(/ 1 —TTI ` 0'J �J SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE DOMESTIC WELL SAMPLING:-<General Mineral/Coliform Bacteria (439 1) Vnibromochloropropane(4392) ' Arsenic(4393) INTENDED USE Pi Domestic/Private ❑ Irrigation/Agricultural [] industrial ❑ 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 ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #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 ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Sched LlSteel F1Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped 1-1 Free Fall ❑ Other 11 Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal 17 Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ 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. MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697G`� SIGNED l�l Ll/' TITLE �CDATE kin �a O �N N� DEPARTMENT U E NLY z�Application Accepted By Date q C I Area Employee ID# Grout Inspection By Date D� F1 SPECIAL Well Permit Pump Inspection By � � �W� Date �`,� \-L\q X \ I 1 WAIVER Received Soil Boring Inspection By, Date Constructed Well 4epth - ft COMMENTS / I�cCC Yt 'S w w lI rc� PE Sc Receivedheck Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted ervice Request# ` F EHD 43-06 8/01116 WELL/PUMP PERMIT