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D WELL/PUMP PERMIT �;! ( SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 952 - (710-3420 4 NON-REFUNDABLE PE MIT CALL 299 953-7697 FOR INSPECTIONS EXPIRES 1 YE FROM DATE ISSUED ii� t cn JOB ADDRESS CITY/ZIP m �y D CROSS STREET 1V v APN ��'D - PARCEL SIZE•LAND USE APPLICATION# 0 Cn 05 OWNER NAME PHONEKDW /' r8y �? OWNER ADDRESS CITY/STATE/ZIP r.;(-r 1 CONTRACTOR PHONE CONTRACTOR ADDRESS QLoW 1A1_de / _M CITY/STATE/ZIP 1 4ZC-04 FA 141, SUBCONTRACTOR PHONE SUBCONTRACT ADDRESS C Y/$TATE/ZIP LICENSE 57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE DOMESTIC WELL S PLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ 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-Servic ell ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump Pump Replacement ❑ Pump Repair n 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 I l 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(941b bag/5-10 gal water) ❑ Sand Cement sack rnix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall I I Other n 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 I Other HP Pump Set ft Standing Water Level ft I HEREBY CER 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 CURREINR AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKOMPENSATION LAWS. MI I U V TICE REQUIRED F I SPEC ONS -PLEASE CALL (209) SIGNED TITLE DATE 04 40AH �Y PARTMENT U E ONLY l� //'//��' Application Accepted By �_JDate I Area ( Employee ID#�` --- Grout Inspection By Date [ASPECIAL Well Permit 1L Pump Inspection By i lrisyt)u sa6ern Date bit Ad C] WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received ec Amount Permit/ Cod s InfoB -Vas emitted Date Service Request# Invoice# Well ID# 2z l�1D 031 EHD 43-06 8/01/16 WELL/PUMP PERMIT