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WELL/PUMPjPERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CAL �2^y09 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DA^�TE ISSUED Z I 'e C '�_ CITY/ZIP L�Th�[/I� t+1 33(/ JOB ADDRESS m CROSS STREET n . ' (, e. f Q D 'I '_ Wim+ APN " PARCEL SIZE e• LAND USE APPLICATION# o OWNER NAME ` C r PHONE y OWNER ADDRESS 30073� � / �' L�� VIA- CITY/STATE/ZIP (fA � �J � ^� CONTRACTOR Tt:.a1 A (,1 / Mall 0• /fr^�el�l(�� r PHONE /-1///—t -2�gq - C CONTRACTOR ADDRESS (]L �i�1.+S�Yl�S I L✓<�7 CITY/STATE/ZIP .a J )' C..§Z-/�yJ2/L SUBCONTRACTOR T PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP 1 V1)D9 LICENSE KC-57 I 1 C-61 1-1D-09 1160 09q 5Y Other NUMBER EXPIRATION DATE 3112 DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ 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 ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other 11Monitoring Well(s) #of wells :019!0�11 Boring(s) _ #of borings Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair Li New Pump I Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary Xi Auger ❑I Cable Tool ❑ Push Point ❑ Other Proposed Well Depth 20-S G ft Excavation _& in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched 11Steel ElPlastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method X.Pumped X Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other Concrete Pedestal F1 Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP ❑ Submersible[] Turbine ❑ 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 953-7697 4 }} [" j /� SIGNED G�' �� TITLE Qilho� )Sf DATE J/2-12-V L MIENTL TY LT D P R DEPARTMENT USE qNLY Application Accepted By YDate +� f-1 Area Employee ID# Grout Inspection By R04 Date ❑ SPECIAL Well Permit Pump Inspection By �, ', Date Ll WAIVER Received Soil Boring Inspection By o�, �j'� kms/ Date Constructed Well Depth ft COMMENTS PE Sc Received he Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# *;2.;2_V7,2_3 5h1 00 S 1 EHD 43-06 8/01/16 WELL/PUMP PERMIT