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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 PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 12 d. JOB ADDRESS Z�`1 "1 C{VIII✓i CITY/ZIP Ewa&' CROSS STREET I, GG�VIA�j Q i APN I '(46&" 1 I�) PARCEL SIZE/:�00 LAND USE APPLICATION# o OWNER NAME 3a1 r'66"r`^' -Q � PHONE z C��t�1r ��11 C�J.J ��f 8% OWNER ADDRESS 1�.� lJ f3`I� "{� CITY/STATE/ZIP [r- ,-CI j��QJ CONTRACTOR _tAw sf I i l f' ) SV\r- yA�.'P�.HO(+NE '/+� i ,'l CONTRACTOR ADDRESS, A'16p,j I2..L% CITY/STATE2IP f ' )1- I G t 1A ., f SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CHIT/Y/SSTATEMPP LICENSE q�<--57 D C)-61 D D-09 ❑Other NUMBER_Y.L.t...l C.. EXPIRATION DATE DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE omestic/.Private ❑Irrigation/Agricultural '❑Industrial ❑Water Quality Monitoring ❑SoilSampling/Chara D Public Water System #[[C((,�E Ven If different from Owner. Water System Name Contact Name or Phoria Number S81 0 TYPE OF WORK ❑New Well .placement Well U Well Alteration/Modification ❑Other_ ��Q D Monitoring Well(s) #Of wells D Soil Boring(a) #of borings D Geotechnica —S AtUIN ri SH OU Well 0 TMNICa Well Renewal Cross-Connection,Repair H� PRNTA� ❑New PumpD Pum Replacement ❑Pump Repair 0 Raise Well Casing LTH WELL CONSTRUCTION Drilling Method S]`Mud Rotary ❑Air Rotary ❑Auger D Cable Tool ❑Push Point ❑ Other ! Proposed Well Depth G ft Excavation 1_in diameter ❑Open Bottom Gravel Pack/Gravel Size C, ,jn diameter ❑Conduct Casing in diameter / Conductor Casing Depth ft Well Casing Diameter, In, Thickness/Gauge/ASTM Sched .7.rly ❑Steel Vlastic ❑Stainless Steel ❑Other Grout Seal Depth .oft D Neat Cement(94 lb bagl5-10 gal water) ❑Sand Cement sack mix17 gal water (Bentonite(20%solids) ❑Other Grout Placement Method ❑ umped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By 0 Driller. ump Contractor D Other ❑Concrete Pedestal DDimenslons:Width ft Length ft Thick in ❑.Christy Box ❑Stove Pipe PUMP D Submersible❑Turbine D 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. MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED TITLE G CN!'�' e DATE J - I *w ti U' U ISS EP RTMENT U 1114\ Application Accepted By' f� Date�� /r Area'' -1 -� Employee Grout Inspection By Date ❑ SPECIAL W@II Permit Pump Inspection By Date Q WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check# Amount Date Permit/ Invoice# Well ID# Codes Info IS, as Remitted Service Re NU # fl GjLAI 19(1WhC;::7 EHD43-06 8101/16 WELL/PUMP PERMIT