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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 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 1119-633 I��1� CITY/ZIP R l JG h X15 3 bl m c D CROSS STREET C01irrej J&-A APN PARCEL SIZE `J LAND USE APPLICATION# A m OWNER NAME ��V`J �� PHONE �1S-31-71 N 16'� � ///��) G� OWNER ADDRESS 1� 'yGc J� a _ CITY/STATE/ZIP 1"IpC�( C, Ci 53 CONTRACTOR 1�lQ�S r�+ � ) �1 1 j K 1_1nr4 _ /�/PHONE 1�� CONTRACTOR ADDRESS t`"1 h 1 V t�S __ _ CITY/STATE/ZIP—M" ITY/STATE/ZIP JV l.0 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 11 C1-61 II D-09 Other NUMBER &WkZZ EXPIRATION DATE DOMESTIC WELL SAMPLING: Fi General Mineral/Coliform Bacteria(439 1) _l Dibromochloropropane(4392) Arsenic(4393) INTENDED USE Domestic/Private 11Irrigation/Agricultural I_I Industrial F1Water Quality Monitoring Ll Soil Sampling/Charact J Public Water System 7' If If different from Owner: Water System Name Contact Name or Phone Number 14- � s TYPE OF WORK L ew Well I Replacement Well [I Well Alteration/Modification [I Other k� ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings I i Geotechnical of o ge019 Ll❑ New pfU�ervice WPum Replacement ❑ Pump Rl Li e air e Well Renewal ❑ Raise Well CasLl Cross-Connection Repair H EN 1RONM COUN7Y WELL CONSTRUCTION �NTMENT Drilling Method')(Mud Rotary ❑ Air Rotary i Auger ❑ Cable Tool ❑ Push Point I I Other Proposed Well Depth36yy ft Excavation _12— in diameter I I Open Bottom Gravel Pack/Gravel Size in diameter Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter 1, in Thickness/Gauge/ASTM Sched 2 ^ _ i I Steel >01astic F i Stainless Steel i I Other Grout Seal Depth ?_00 ft ❑ Neat Cement(94 1h bag/5-10 gal water) I I Sand Cement Sack mixl7 gal water Bentonite(20%solids) ❑ Other _ Grout Placement Method Pumped n Free Fall Ii Other _ Retardant/Accelerator(name) PEDESTAL Installed By '_i Driller 'L Imp Contractor CI Other ❑ Concrete Pedestal I(Dimensions:Width ft Length ft Thick in I I Christy Box ❑ Stove Pipe PUMP ❑ Submersiblerl Turbine I I 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. 48 HOUR ADVANCE OTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953--7697 SIGNED T ITt-E DATE ( JIM i ^^Aw #1 1 1 `l DEP RTMENT US ONLY Gee,- � Application Accepted By Date Area Employee ID# lev Grout Inspection By Datez �� ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE Sc Received Che Amount Date Permit/ Invoice# Well ID# Codes Info Cash Remitted Service Request# it P �) VVT ^,� EHD43-06 8/01/16 WELL/PUMP PERMIT