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. H WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1 68 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT V CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 2-7o,52- l n 4e r !LG �S cm(V i1 Cln/ZIP 1.G7 0 �1- m �^ }� [ D CROSS STREET•F_TGg4 o,�T>'�((�`2 APN �.C.D7'��-�I t� PARCELSIZEJ• Q LAND USE APPLICATION# A ,7 _qi36_SZSi> y OWNER NAME ?fret I r A� I I C'f, \/ �M1. PHONE V! OWNER ADDRESS 21I �2>� . q4f( CITY/STATE/ZIP CONTRACTOR M&S Dr h�\i hL.PHONE 1 C5C / 61 CONTRACTOR ADDRESS I-t A, J CITY/STATE/ZIP �� r`_7f'-L/. / i C1 1 J SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS ! CITY/STATE/ZIP LICENSE ,C-57 ❑C-61 11D-09 11Other NUMBER /% EXPIRATION DATE Y' )C^'�G•/ DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)C Arsenic(4393) INTENDED USE X Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Chara 9*3 0 Public Water System _ r If different from Owner: Water System Name Contact Name or Phone Number , TYPE OF WORK New Well D Replacement Well ❑Well Alteration/Modification D Other 0 Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of 19 e ❑Out-Of-Service Well C1 Out-Cf-Service Well Renewal ❑Cross-Connection Repair VN NN h❑New Pum ❑Pum Replacement 0 Pum Repair ❑Raise Well Casing0taiFUNry WELL CONSTRU TION FNT Drilling Method),<Mud Rotary ❑Air Rotary D Auger D Cable Tool D Push Point ❑ Other Proposed Well Depth 0C-'� ft Excavation 17 in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameser_.[_jQonductor Casing Depth ft Well Casing Diameter/ in Thickness/Gauge A9TM Sche 2.r L D Steel Plastic El StainlessSteel ❑Other Grout Seal Depth 00 ft D Neat Cement(94 Ib bag/5-10 gat water) ❑Sand Cement sack rnix/7 gal water Bentonite(20%solids) ❑Other Grout Placement Method Pumped 0 Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller Pump Contractor ❑ Other ❑Concrete Pedestal❑Dimensions:Width ft Length It Thick in D Christy Box ❑Stove Pipe PUMP ❑Submersible0 Turbine D Other HP Pump Set It 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 SIGNED .�.. __-.S. �+ TITLE ,r'�f`�i I/,-- DATE L/f" rf 7 .1 7 /r r 7 0 EP RTMENT )S.,E NLY /qApplication Accepted ByGsou --J Date `f L ( Area.G^ 0!C Employee ID# Grout Inspection By Date ❑ PECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE Sc Received C #/ Amount Date Permit/ Invoice# Well ID# Codets Wo a jRemitted Service Request#