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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-�`TOCKTON 5 68-3420 NON-REFUNDABLE /PERMIT Al, CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS !/ ! A f �J (]� ��zl 7�' ' CITY/ZIP � �✓ 5�`Z m CROSS STREET ��/�' APNii'D'�i/O'�/ -?/7-`PARCEL SIZE LAND USE APPLICATION# o c p p m OWNER NAME � � /T /'/ O/y� PHONE C� y OWNER ADDRESS ec'3,' . CITY/STATE/ZIP CONTRACTOR / /`,/// `J�', `i—YL c��7� PHONE CONTRACTOR ADDRESS ^IL D �L—c,�{/�C' CITY/STATE/ZIP J , / / J SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE I I C-57 I I C-61 Ll D-09 ❑ Other NUMBER EXPIRATION DATE DOMESTIC WELL SAMPLING: 1 I General Mineral/Coliform Bacteria(4391)LI Dibromochloropropane(4392)❑ Arsenic(4393) INTENDED USE Il Domestic/Private I Irrigation/Agricultural ❑ Industrial I I Water Quality Monitoring ❑ Soil Sampling/Characterizon I Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK I I New Well ❑ Replacement Well ❑ Well Alteration/Modification Other I I Monitoring Well(s) #of wells I1 Soil Boring(s) #of borings ❑ Geotechnical r" I I Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair j9 ?019 I New Pum um Replacement LI Pum Repair F] Raise Well CasingE AQU/ WELL CONSTRUCTION Drilling Method I I Mud Rotary I Air Rotary I Auger I Cable Tool I I Push Point I I Other Proposed Well Depth ft Excavation in diameter I I Open Bottom ❑ Gravel Pack/Gravel Size in diameter I I Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched F1Steel I I Plastic ❑ Stainless Steel I I Other Grout Seal Depth ft I I Neat Cement(94 lb bag/5-10 gal water) 1-1 Sand Cement sack mix17 gal water I I Bentonite(20%solids) I I Other Grout Placement Method I I Pumped I I Free Fall I Other 11 Retardant/Accelerator(name) PEDESTAL Installed By I I Driller I I Pump Contractor ❑ Other 1 I Concrete Pedestal I(Dimensions:Width ft Length ft Thick in a Christy Box I_I Stove Pipe PUMP ubmersiblel I Turbine LI Other HP Pump Set —ft Standing Water Level L'l ft I HEREBY CE TIFY 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. MIN !:� �ENO�TICE REQUIRED FOR IN PIECCT,IIOINS -PLEASE CALL (209)953 6697 SIGNED TITLE fid%�/"'\ DATE .Cf f57 P { EP RTMENT U E N L Y -16 Application Accepted By / Date yL Area Employee ID# VY — Grout Inspection By \ h 'gyp p Date Cl PECIAL Well Permit Pump Inspection By �� ly�V�/W\ ALL Date Ll WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE Sc Received Amount Date Permitl Invoice# Well ID# Codes Info ---CTsh Remitted Service Request# W PO 036-61-75 EHD 43-06 8/01/16 WELL/PUMP PERMIT