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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 W ITYIP F�I OI�Oa ag-320 m JOB ADDRESS C /Z � m l j� j�I D CROSS STREET Vl I�(D APN �q -v�V � v PARCEL SIZE LAND USE APPLICATION# I (A Jfi PHONE lJ'�' /' N OWNER NAME G �j��7� �r OJ l �j/-3 7 ui OWNER ADDRESS �- 1 Il f W R , _v CITY/STATE/ZIPT1 G0/V1 n� (✓64 Vj2_ 7 CONTRACTOR _�y tt/1 ]V Ills W I I 11 O I N� y��PHONE !V 1 rZ-`• l II7`0 CONTRACTOR ADDRESS 1 I I L �/ CITY/STATE/ZIP /�/W W J� �/� 1 qJ 1/ / SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS 11F1O CITY/STATE/Z 'IP r��1- LICENSE C-57 C-61 ❑ D-09 Other NUMBER U�zZ EXPIRATION DATE V ''/L7.2—I DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) 1 Dibromochloropropane(4392) Arsenic(439 INTENDED USE XDomesticiPrivate ❑ Irrigation/Agricultural 1 Industrial I i Water Quality Monitoring ❑ Soil Sampling/Ch �i r ❑ Public Water System vkA If different from Owner: Water System Name Contact Name or Phone NAPP 9 TYPE OF WORK -)<New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other #of borings AQ fborings L] LiLiMonitoring Well(s) #of wells Soil Boring(s) Geotechnic�FIIMD_� Co LlOut-Of-Service Well F] Out-Of-Service Well Renewal ElCross-Connection Repair T/aN– Fly?u'v�Y 11 New Pum ❑ Pum Replacement ❑ Pum Repair Li Raise Well CasingART WELL CONSTRUCTION Drilling MethodSulud Rotary ❑ Air Rotary LI Auger ❑ Cable Tool 11 Push Point ❑ Other Proposed Well Depth�ft Excavation , in diameter LI Open Bottom >;1 ,ravel Pack/Gravel Siz2 _in diameter ❑ Conductor Casing in diameter / Condu^cto�G,asing Depth ft Well Casing Diameter In Thickness/Gauge/ASTM Sched .6j I J Steel Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft LI Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water Bentoni;Cmped 0%solids) 11 Other Grout Placement Method ❑ Free Fall ❑ Other I I Retardant/Accelerator(name) PEDESTAL Installed By Li Driller Contractor [I Other Li Concrete Pedestal []Dimensions:m 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. MINIM I^'\ '''OUR ADVANCE NOTICE REQUIRED FO INSPECTIONS - PLEASE CALL (209)r 953-7697 �J SIGNED MINIM= \ .� TITLE_ �/�/r� DATE Ii I r (� r EPARTMENT USE ONLY Application Accepted By D a tealzzll 0 Area 141,V7Employee ID#� Grout Inspection By 4 Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth 2�(- ft COMMENTS PE SC Received Amount nate I Permit/ Invoice# Well ID# Codes Info Cash ttad Service Request# 3 v s�- EHD 43-06 8/01/16 WELL/PUMP PERMIT