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E I WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABL PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 'I YEAR FROM DATE ISSUED JOB ADDRESS CITY/ZI m D CROSS STREET APN �" PARCEL SIZE©• LAND USE APPLICATION# A q31-1a�� OWNER NAME PHONE �? OWNER ADDRESS AA CITY/STATE/ZI CONTRACTORPHONE CONTRACTOR ADDRESS l/1! CITY/STATE/ZIP SUBCONTRACTOR A 4 PHONE SUBCONTRAPTqR ADDRESS (11 /STATE/ZIP LICENSEC 57 El C-61 Li D-09 ❑ Other NUMBER EXPIRATION DATE DOMESTIC WELLS MPLING: F-1 General Mineral/Coliform Bacteria (4391) 1 1 Dibromochloropropane(4392) 1 Arsenic(4393) INTENDED USE X.Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial CI 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 ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service Vell ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth 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 ❑ Steel ❑ Plastic ❑ 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 ❑ Pumped ❑ Free Fall ❑ Other [I Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor CI Other ❑ Concrete Pedestal 11 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 CERT FY 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 WORKER OMPENSATION LAWS. IN O ICE REQUIRED F INS S - PLEASE CALL (209) 953-7697 SIGNED TITL DATE El IVIOM NTA& T DEP RTMENT SE 7,NLY Application Accepted By Date Area Employee ID# Y`� Grout Inspection By �n Date �}- ❑ PECIAL Well Permit Pump Inspection By '� �1� �l� Q�. i Date ll 01 ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Permit/ Codes Info B Cash emitted Date Service Request# Invoice# Well ID# s EHD 43-06 8/01/16 WELL/PUMP PERMIT