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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 AON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS rI d- ✓/ C= /��'� G�� CITY/ZIP �a' m D ROSS STREET d�� APN Ob�,Z3o O_I PARCEL SIZE `7� !1) LAND USE APPLICATION# 0 OWNER NAME ''N t PH/ONE 'j _s 2.�- 410 OWNER ADDRESS ��V n/" CITY/STATE/ZIP7r�� CONTRACTOR I xiA <r n PHONE J -,f '7L CONTRACTOR ADDRESS �ii t� 1 -72 CITY/STATE/ZIP 4a SUBCONTRACTOR ' / .1—r PHONE SUBCONTRACTOR ADDRESS ZCITY/STAT�pE/Z�IP LICENSE �I-C-57 1 C-61 D-09 I I Other NUMBER J ?9 ' " EXPIRATION DATE �' 1 DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE ❑ Domestic/Privat Irrigation/Agricultural ❑ Industrial 1 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 0 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings I Geotechnical #o ED ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair $ ew Pump ❑ Pump Replacement C Pump Repair ❑ Raise Well Casing 2 e l4 WELL CONSTRUCTION "ANJOAQuI NC Drilling Method +�dVlud Rotary ❑ Air Rotary I I Auger ❑ Cable Tool I I Push Point 0 Other 14PAI—`�®N%l,I`r � . Proposed Well/Depth �,�� ft Excavation �� in diameter I I Open Bottom .KGravel Pack/Gravel Size `T'��I'Vblf or 1 Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter 5 in Thickness/Gauge/ASTM Sched -1 'Q 1l Steel ><Plastic 11 Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) I>Sand Cement sack mix/7 gal water 11 Bentonite(20%solids) ❑ Other Grout Placement Method Pumped ❑ Free Fall I I Other I l Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor. ❑ Other ❑ Concrete Pedestal Li Dimensions:Width ft Length ft Thick Jn I Christy Box _ Stove Pipe PUMP ,rte Submersible❑ Turbine 1-1 Other HP 1-0 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. MINIMUM 4R HOUR AD , NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED /� .?�. TITLE C"C/r✓�� DATE J -it yL ' +1 U Z EY R 11`x1 EN T USC 0NLY Application Accepted y Date ?/ Area Employee ID# Grout Inspection By Date I'M ❑ 1 PECIAL Well Permit Pump Inspection By Date_ 1 WAIVER Received Soil Boring Inspection By Date- Constructed Well Depth ft COMMENTS PE SC Received Check!/ Amount Date Permit/ Invoice# Well ID# Code& Info Elyn '-Cssli Remitted Service Reg uest# c 2 EHD 43-06 8/01116 WELL/PUMP PERMIT