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i WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE FEIII IC CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED J / t'n JOB ADDRESS / t s YL� CITY/ZIP w_�� G�o4 rn D CROSS STREET +� APN V u( / L!� PARCEL SIZE'�� LAND USE APPLICATION# o o� h OWNER NAME cJ } �//C( 1�^�G� PHONE ��!c7��"�i' 7 L_! (Mn OWNER ADDRESS /iiV'�.Li CITY/STATE/ZIP u � CONTRACTOR �tT J I� .� T.ZLL ! PHONE 3 J�_ r ��} CONTRACTOR ADDRESS 1,90 If � ^ CITY/STATE/ZIP 1-610 6jPt1A11' -7 SUBCONTRACTOR SUBCONTRACTOR y ��',�r ��`( � L��J A/'.d. PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ;/—C-57 ❑ C-61 ❑ D-09 i Other NUMBER e 7 2 7 24%'= EXPIRATION DATE DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE ❑ Domestic/Private - rigation/Agricultural ❑ Industrial I I Water Quality Monitoring Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK a<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 LI Cross-Connection Repair e Pum p ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method>e Mud Rotary ❑ Air Rotary I Auger Cable Tool LI Push Point I I Other Proposed Well Depth < <_)7) ft Excavation _fV in diameter P Open Bottom X Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter/ Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched i Steel Plastic Stainless Steel Other Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ;kT Sand Cement f sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method Pumped ❑ Free Fall I1 Other i Retardant/Accelerator(name) PEDESTAL Installed By Driller I1 Pump Contractorl9 Other CI Concrete Pedestal I'Dimensions:Width 7 ft Length ft Thick in I 1 Christy Box ❑ Stove Pipe PUMP .KSubmersiblei Turbine rOther 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. MINVIM'U/M�LJ(8 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED !/'c/✓f�? .//,'Cdj� TITLE (J DATE "2 r- i u w O 1 ' O> y i � i _ DEPARTMENT USE ONLY Application Accepted By q�� j. Date /_ Area p yee ID# �V Grout Inspection By �W `Qw" Date/p � � �� ❑ SPECIAL ell Permit Pump Inspection By Date 1 WAIVER Received Soil Boring Inspection By Dale Constructed Well Depth ft COMMENTS �j/�� ul•y IO'3 (C /" X 70 SI-fPA iiLL1 Cr.� �- PE SC Received Amount Date Permit/ Invoice# Well ID# Codes Info Cash Remitted Service Re uest# 7� ) EHD 43-06 8/01/16 WELL/PUMP PERMIT