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WELL/PUMP PERMIT , D SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON I I y - NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS In EXPIRES 1 YEAR FRW DATE ISSUED IVAN JOB ADDRESS POW E Mb CITY/ZIP (NAVAhm ,c� /1� �7 D CROSS STREET APN t/�'�/ �U (�PARCEL SIZE LAND USE APPLICATION# S OWNER NAME PHAll ONE ,� y OWNER ADDRESS CITYISTATE/ZIP _cl��, CONTRACTOR PHONE �� - / CONTRACTOR ADD I rk CITY/STATE/ZIP SUBCONTRACTOR A PHONE SUBCONTRACTRR ADDRESS TY/STATE/ZIP �j/ LICENSE -57 ❑ C-61 I I D-09 I I Other NUMBER EXPIRATION DATE ✓( DOMESTIC WILL SA PLING: ❑General Mineral/Coliform Bacteria(4391)I 1 Dibromochloropropane(4392)I I Arsenic(4393) INTENDED USE I. omestic/Private I I Irrigation/Agricultural ❑ Industrial I I Water Quality Monitoring 1-1 Soil Sampling/Characterization I Public Water System If different from Owner: Water System Name Contact Name or Phone Numb bA TYPE OF WORK ❑ New Well ❑ Replacement Well I I Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells I 1 Soil Boring(s) #of borings ❑ Geotechnical tic V_s:j) i l Out-Of-Service II ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair MA I I New Pump Pump Replacement F1 Pump Repair I I Raise Well Casing WELL CONSTRUCTION SAN JOAQUIN COON Drilling Method I I Mud Rotary F I Air Rotary I I Auger I_1 Cable Tool I I Push Point 11E Other M/IR Ty -11 IAL Proposed Well Depth ft Excavation in diameter I I Open Bottom F1 Gravel Pack/Gravel SizeN OEP/�RTMLrN�ipmeter I I Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched I I Steel F1 Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft I I Neat Cement(94 Ib bag/5-10 gal water) n Sand Cement sack mix/7 gal water i I Bentonite(20%solids) !I Other Grout Placement Method i! Pumped I i Free Fall CI Other 11 Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller 1 I Pump Contractor ❑ Other I 1 Concrete Pedestal ijDimensions:Width ft Length ft Thick in I I Christy Box ❑ Stove Pipe PUMP I ubmersible[I Turbine I 1 Other HP Pump Set ft Standing Water Level ft I HEREBY CER FY 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. 1 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 99MPENSATION LAWS. M NI 48 H A V C NO ICE REQUIRED F INSPEC 10BS -PLEASE CALL (209) 953-76 7 SIGNED TITLE DATE fl 1 IAV _PARTMENT USE ONLY Application Accepted By Date Area mployee ID# � Grout Inspection By '/ Date ❑ PECIAL Well Permit Pump Inspection By Vt Date qQ 1)Z I I I WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE Sc Received fie Amount Date Permit/ Invoice# Well ID# Codes Info B ash Remitted I Service Request# SO Z Z EHD 43-06 8/01/16 WELL/PUMP PERMIT