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WELL/PUMP PERMIT +' � SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA� 0 L"EEL NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <n JOB ADDRESS CITY/ZIP m A D CROSS STREET APN PARCEL SIZE O LAND USE APPLICATION# o OWNER NAMEay-u PHONE ' y OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR �SU—(�4Qft_lC. PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR A 114 PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 f_1 C-61 71D-09 11Other NUMBER EXPIRATION DATE1. 31 . DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) I Dibromochloropropane(4392) I Arsenic(4393) INTENDED USE o 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 Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary CI 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 I I Steel ❑ Plastic U Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water ❑ Bentonite(20%solids) I_I Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersible❑ Turbine ❑ Other HP==LUI 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. MINV NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 954,769 SIGNED TITLE i'°/�'2 DATE rl SA J A UI O N EP RTMENT U E NLY Application Accepted By , Date Area Employee ID# Grout Inspection By 1 ' Date ❑ SPE IAL Well Permit Pump Inspection By 1h�1b'�RCn E'er)2 Date 1�1 ��1 ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS V�O�an PE SC Received Check#/ Amount Permit/ Cods Info Cash emitted Date Service Request# Invoice# Well ID# am EHD43-06 8/01/16 WELL/PUMP PERMIT