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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 SQRMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 Y R FROM DATE ISSUED / JOBADDRESS CITY/ZIP A Alt D _ CROSS STREET A ��, r to( APN 0}. 0 WPARCEL SIZE LAND USE APPLICATION OWNER NAME � �-1[T O L (� PHONE /�v �7 h /Iy• •�7 N OWNER ADDRESS Fj V/fig-f /�� (o.'T S.104C 7✓CITY/STATEILP 1CL��V' ` �'` �l O CONTRACTOR 4"f /�t�' PHONE � y CONTRACTOR ADDRESS CITY/STATEIZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITYISTATEIZIP LICENSE '.i C-57 '_i C-61 G D-09 ❑Other NUMBER EXPIRATION DATE r DOMESTIC WELL SAMPLING:17 General Mineral/Coliform Bacteria(4391) 1 Dibromochloropropane(4392)1 1 Arsenic(4393) I INTENDED USE omestic/Private C Irrigation/Agricultural ❑Industrial G Water Quality Monitoring ;_I Soil Sampling/Characterization L 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 n Soil Boring(s) #of borings ❑Geotechnical a of borings Out-Of-Baru ce Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair New Pum ❑Pum Replacement o Pum Repair ❑Raise Well Casing WELL CONSTRUCTION Drilling Method i Mud Rotary a Air Rotary L1 Auger [1 Cable Tool C Push Point Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom 1 1 Gravel Pack/Gravel Size in diameter I Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_in Thickness/Gauge/ASTM Schad ❑Steel ❑Plastic j Stainless Steel I.1 Other Grout Seal Depth ft u Neat Cement(94 Ib bag/5-10 gal water) I Sand Cement Sack mix/7 gal water E Bentonite(20%solids) ❑Other Grout Placement Method i.i Pumped ❑Free Fall []Other ❑Retardant/Accelerator(name) fPEDESTAL Installed By 1 Driller ❑Pump Contractor it Other D VL oncrete Pedestal DDimensions:Width ft Length It Thick in D Christy Box -1 Stove Pipe PUMP Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level ft I HEREBY CE 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 WORKERS COMPENSATION LAWS. / MIMNKJM 48 HOU _ NCE NOTICE REQUIRED FOR INSPE TIONS-PLEASE CALL(209)953-7 97 / SIGNED TITLE DATE �- .-�[- RF 1T CE jV�® qR OgQN�NC� Dip�N( N>1' eAf T EPA TMENTzU--��YQ �a1�C Application Accepted By � Date ` z �� J Area�� Employee ID#_ Grout Inspection By Date 1� f_ 1 SPECIAL Well Permit Pump Inspection By Q` Date V��ZW LI WAIVER Received Soil Boring Inspection By Date \ Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info ash Remitted Service Re uest# Z 71 � ED43-C16 revised 4/14/18 W22-YI.. /��ff /it WELL/PUMP PERMIT