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j WELL/PUMP PERMIT V DE31 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON�K`.! 0Y0 NON-REFUNDABLE PERMIT C L 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED I C• N JOB ADDRESS // CIN/ZIPNyj�n 0q W—TL� m A 117 �J/ D CROSS STREET APN , �� PARCEL SIZE I LAND USE APPLICATION D1_ # �j A OWNER NAME PHONE t LJM OWNER ADDRESS (,!i CITY/STATE/ZIPq...rj�[y�_ CONTRACTOR ( PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP �V�/L SUBCONTRACTOR PHONE 061 SUBCONTRAVC-57 ADDRESS C TY/STATE/ZIP LICENSE [I C-61 I I D-09 ❑ Other NUMBER EXPIRATION DATE DOMESTIC WELL SAM ING:I I General Mineral/Coliform Bacteria(4391)n Dibromochloropropane(4392)I I Arsenic(4393) INTENDED USE omestic/Private I I Irrigation/Agricultural [I Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization 1-1 Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK I I New Well 1i Replacement Well �� Well Alteration/Modification I Other I I Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings 1 Geotechnical #of borings I I Out-Of-ServiceW II 1 1 Out-Of-Service Well Renewal I I Cross-Connection Repair 11 New Pum Pum Replacement n Pum Repair 1 Raise Well Casing WELL CONSTRUCTION Drilling Method I I Mud Rotary I I Air Rotary 1_I Auger I I Cable Tool I Push Point F1 Other Proposed Well Depth ft Excavation in diameter I] Open Bottom I I Gravel Pack/Gravel Size in diameter I Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched F] Steel 11 Plastic [I Stainless Steel 1.1 Other Grout Seal Depth ft II Neat Cement(94 Ib bag/5-10 gat water) ❑ Sand Cement sack mix/7 gal water 1 I Bentonite(20%solids) ❑ Other Grout Placement Method I I Pumped I I Free Fall 11 Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By I I Driller I I Pump Contractor ❑ Other I 1 Concrete Pedestal I IDimensions:Width ft Length ft Thick in 1I Christy Box I Stove Pipe PUMP Submersible[I Turbine I-1 Other HP Pump Set ft Standing Water Level ft I HEREBY CERftlTHAT 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. I M M 1C TICE REQUIRED FO INSPE TIONS -PLEASE CALL (209) 9 769 A /VSIGNED TITLE DATE 1 /R Op F P RTMENT USE C1 N L Y Application Accepted By Date Area Employee ID#� Grout Inspection By Date�1 11 9PECIAL Well Permit Pump Inspection By Date V I I WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE Sc Receivedheck Amount Permit/ s Info B ash mitted Date Service Request# Invoice# Well ID# EHD 43-06 8/01/16 WELL/PUMP PERMIT