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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 CALL 209 953-7694 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Ln JOB ADDRESS ICP MifJat) ��t!/''z v CITY/ZIP Z,k m CROSS STREET utL"C' t/' APN 1C�S i q PARCEL SIZE -�� LAND USE APPLICATION# OWNER NAME �fl Ls6 r Zk1 h-t, PHONE OWNER ADDRESS CITY/STATE/ZIP y CONTRACTOR r �✓Ll�"l PPHOONNEf��//5�'��- CONTRACTOR ADDRESS/'� 2dCITY/STATE/ZIP SUBCONTRACTOR l�' - PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP / LICENSE )C-57 I I C-61 I I D-09 ❑ Other NUMBED � / EXPIRATION DATE DOMESTIC WELL SAMPLING: eneral Mineral/Coliform Bacteria (4391) ibromochloropropane(4392) Arsenic(4393) INTENDED USE I Domestic/ rivate ❑ Irrigation/Agricultural I! Industrial b Water Quality Monitoring 11 Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK > (ew Well I_I Replacement Well ❑ Well Alteration/Modification I Other Li 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 ew Pum 1 Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method-<Mud Rotary _I Air Rotary I I Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ,�� ft Excavation ��` in diameter El Open Bottom ravel Pack/Gravel Size in diameter I i Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter C in Thickness/Gauge/ASTM Sched ti�V ❑ Steel XPlastic I I Stainless Steel I I Other Grout Seal Depth !jV ft ❑ Neat Cement(94 lb bag/5-10 gal wate/) Land Cement Id _� sack mix17 gal water I I Bentonite(20%solids) ❑ Other Grout Placement MethodA?Oumped ❑ Free Fall I I Other I I Retardant/Accelerator(name) PEDESTAL Installed By K.Driller ❑ Pump Contractor Other 1 Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in Ll Christy Box I Stove Pipe PUMP .P+Zubmersiblei i Turbine ❑ Other HP Pump Set ft Standing Water Level ft 1 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 VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953--`7697 SIGNED TITLE ��L/�`�Tt✓ DATE g. 2 $ 0 Q I T E T D A R T M E N T U S E G N L Y Application Accepted By Dat Area__L Employee ID# Grout Inspection By Date J I ❑ PECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspction By A Date Constructed Well Depth ft COMMENTS�Al J^ tit 7 PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# P60-Mu 4 l �3� 1 l2 Of EHD 43-06 8/01/16 WELL/PUMP PERMIT