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j WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1.868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED pp '''�^ 1 o U h / J�r�ln m JOB ADDRESS 23()�`] �lac.�T'�/'�'f �`�t�� CITVIZIP �1 �c� CROSS STREET�,�.rp5_�. t;J°�'+ (2{,R/1 + APN 1 Y.:�"I I U � �� PARCEL SIZE t•J If r� LAND USE APPLIICCATION# f� may,t A In OWNER NAME �iC))�A'Q-' 11h'Q�i N'l= N t PHONE ��-}`•" - Q4 r� 1 "�Ga``t N OWNER ADDRESS (^q 1 A wt *•f x S Dr CIN/STATE/ZIP CONTRACTOR /"\G S P�i S h it d l i t'r JC-• PHONE S/ 2 19 CONTRACTOR ADDRESS " A'% l5 12 lj CITYISTATE/ZIP y'n V 1 U d'FS Ty SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS L,-WL, f / C.te"J 22-. EXPIRATION DATE '1 r LICENSE C-57 ❑C-61 11D-09 ❑Other NUMBER n <? DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE llxDomestic/Private ❑ Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑ Public Water System P If different from Owner: Water System Name - Contact Name or Phone Nu TYPE OF WORK New Well ,Replacement Well ❑Well Alteration/Modification ❑Other ❑Monitoring Well(s) #of wells ❑Soil Boring(s) uofborings ❑Geotechnicalkdy 5ofborings. 11 Out-Of-Service Well [I Out-Of-Service Well Renewal Cl Cross-Connection Repair J.:/� 4 12019 11New Pump ❑Pump Replacement ❑Pump Repair 1)Raise Well Casing SAN JOA WELL CONSTRUCTION HEA(-j H D NMENTAL Drilling Method)<Mud Rotary ❑Air Rotary C1 Auger ❑Cable Tool [I Push Point 11 Other EpARTM Proposed Well Depthft Excavation 02 f I in diameter ❑Open Bottom `9�Gravel Pack/Gravel Size in diameter ❑Corwductor Casing in diameter / Conductor Casing Depth ft / Well Casing Diameter rP in Thickness/Gauge/ASTM Sched -2.a ,0 0 ❑Steel lastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water Bentonite(20%solids) ❑Other Grout Placement Method Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller Pump Contractor ❑ Other ❑Concrete Pedestal❑Dimensions:Width ft Length It Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible❑Turbine ❑Other HP 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. MIJM 48 HOUR ADVANCENO_ILCE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9553-769p7 SIGNED �..» '+ r--.�,;1- l..✓^'- .-.......,^-^ TITLE L)r-7l/Ye'r.' DATE 5/. f•-r.r' P s -------------- ----------- ------------------- ------------ II I ,S r, J k- —a G EP RTMENT USE ONLY Application Accepted By - Date G, Area W Employee ID#d Grout Inspection By Date ❑ PECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received -Chec Pv Amount Date Permit/ Invoice# Well ID# Code Info B ash Remitted Service Re uest# ,n[II/pl l,lp pFpAAIT