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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 E I CALL 209 953-7697 FOR INSPECTIONS EXPIRES 'I YEAR FROM DATE ISSUED r � Ps Ln JOB ADDRESS __ - / � CITY/ZIPA cz"' , �tSS 1�-11 m !Y A 7 9 D CROSS STREET V✓'l/r APN lJ l /�LJ. PARCEL SIZEwL-� LAND USE APPLICATION# A ��'IC F' !! m OWNER NAME ��.} d /r' � � PHONE �vr7j'-"(4 � Z_? ui OWNER ADDRESS /I�/YID„�i CITY/STATE/ZIP CONTRACTOR t� l ��7/ ��S✓ LL C. 1 PHONE 3> �j r CONTRACTOR ADDRESS �' e,,Z ¢t-78 CITY/STATE/ZIP /If_/0 _)'iS1 SUBCONTRACTOR ,/e_ �� Y j I-�J 'V PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ,,;ACC-57 ❑ C-61 0 D-09 [1 Other NUMBER `7 2 ? : EXPIRATION DATE ” DOMESTIC WELL SAMPLING: ' General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE ❑ Domestic/Private brrigation/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 [New Well Cl Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings 10 Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method Mud Rotary ❑ Air Rotary ❑ Auger Cl Cable Tool I Push Point 1 Other Proposed Well Depth 1� 07) ft Excavation /V in diameter [I Open Bottom XGravel Pack/Gravel Size in diameter [1 Conductor Casing in diameter// Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched I Steel >01astic I I Stainless Steel 11 Other Grout Seal Depth c ft ❑ Neat Cement(94 Ib bag/5-10 gal wate/) >]'Sand Cement_��f sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method>4pumped rl Free Fall ❑ Other I I Retardant/Accelerator(name) PEDESTAL Installed By .k�Driller fl Pump Contractorlo I I Other ❑ Concrete Pedestal FiDimensions:Width 7 ft Length ft Thick in n Christy Box ❑ Stove Pipe PUMP ,Submersible❑ Turbine I I 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 8 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-76C9/7 SIGNED `/'t .//, L� TITLE CJ DATE �� -2- 7' F 1 1 11 FE z "'S O > Oj r D PARTMENT USE ONLY Application Accepted By Date Area p yee ID# � - Grout Inspection By `Q '/ Date& ❑ SPECIAL ell Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date / Constructed Well Depth ft COMMENTS r[LGl F1/�� uJ�y I0'.3 4-Ac /";X j!-0Scly�- P '� PE SC Received Amount Permit/ Codes Info Cash emitted Date Service Re uest# Invoice# Well ID# B SID oo , EHD 43-06 8/01/16 WELL/PUMP PERMIT