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WELL/PUMP PERMIT SAN.OAQUIN 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 CITY/ZIP MC ' D CROSS STREETr—lak APN O PARCEL SIZE O' LAND USE APPLICATI N# A OWNER NAME PHONE y OWNER ADDRESS CITY/STATE/ZIP J CONTRACTORPHON CONTRACTOR ADDRESS CITYISTATE/ZIP SUBCONTRACTOR /� L //� PHONE 42) SUBCONTRAC R ADDRESS CI STATE/ZIP 'IZLn Wt LICENSE -57 11 C-61 11D-09 F1 Other NUMBER EXPIRATION DATE DOMESTIC kILL SAMPLING: ❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑ Arsenic(4393) INTENDED USE Domestic/Private I I Irrigation/Agricultural 1 Industrial ❑ Water Quality Monitoring Cl Soil Sampling/Characterization I I Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well 1-1 Replacement Well 1 I Well Alteration/Modification I I Other ❑ Monitoring Well(s) #of wells I I Soil Boring(s) #of borings CI Geotechnical #of borings ❑ Out-Of-ServiceW II 1 1 Out-Of-Service Well Renewal i Cross-Connection Repair F1 New Pum Pum Replacement I 1 Pump Repair 11 Raise Well Casing WELL CONSTRUCTION Drilling Method i 1 Mud Rotary I 1 Air Rotary 1 1 Auger i 1 Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom I I Gravel Pack/Gravel Size in diameter i 1 Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched i1 Steel I I Plastic 11 Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) I I Sand Cement sack mix/7 gal water 1 I Bentonite(20%solids) 1 J Other Grout Placement Method CI Pumped ❑ Free Fall I I Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor F1 Other 1 1 Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersible I_I Turbine I I Other HP Pump Set t�0 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 WORr COMPENSATION LAWS. M I E REQUIREDIF R I SP N -PLEASE CALL(209) 5 7697 SIGNED TIT DATE VIP E VI O M z N'-AL HEALTH DEPART ME 4T -H+�:F EP 1RTMENT U E ONLY e Application Accepted By Date Area ` Employee ID#= V- Grout Inspection By Date nn i 11 'SPECIAL Well Permit Pump Inspection By �� Lt(��O� A Date ll Q7 07/ I q l 17 WAIVER Received Soil Boring Inspection By a Date Constructed Well Depth ft COMMENTSW�L � . PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Qash R mitted Service Re uest# L EHD 43-06 8/01/16 WELL/PUMP PERMIT