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Z 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 In //�� 1'lJ JOB ADDRESS`7* CITYIZIP S]Pf1-D CK 4_,, i 0 CROSS STREET APN�7 ,Z r'nQ'�� PARCEL SIZE LAND USE APPLICATION# p '/ C �'(6{ U�Sr 3�1i�- m Gaylh0 HOltrl�q��( I P�y PHONE N OWNER NAME / / / y OWNER ADDRESS 73/.z MA th SA. p( v �/,/ U�� CITY/STATEfZIP 5•+ CONTRACTOR "`AS.B-/�L S' ©YI�IIKO N�PHONNE'�ZZ�-17�ZP CONTRACTOR ADDRESS i f e'I'l�,n^r CITY/STATE/ZIP Alodo l PHONE SUBCONTRACTOR SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE )�C-57 ❑C-61 0 D-09 D Other NUMBER4(.Aiagz EXPIRATION DATE Zen DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE KDomestic/Private D Irrigation/Agricultural D Industrial ❑Water Quality Monitoring 0 Soil Sampling/Characterization ❑Public Water System If different from Owner: Water Syelem Name Contact Name or Phone Number TYPE OP WGRK New Well ❑Replacement Well [I Well Alteration/Modification 0 Other M of borings D Geotechnical K of borings ❑Monitoring Wells) #of wells ❑Soil Boring(s) ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair ❑New Pump 0 Pump Replacement ❑Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method I41 Mud Rotary D Air Rotary D Auger ❑Cable Tool D Push Point ❑ Other Proposed Well/'Depth� zo it Excavation,12, in diameter ❑Open Bottom *ravel Pack/Gravel Size In diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter._In, Thickness/Gauge/ASTM Sched �y0 D Steel Plastic El Stainless Steel ❑Other Grout Seal DepthZQLV ft D Neal Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mixr7 gal water Bentonite(20%solids) D Other Grout Placement Method Pumped 0 Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller P:Pump Contractor ❑ Other ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick In D Christy Box ❑Stove Pipe PUMP ❑SubmersibleD 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 ONS, I COURRENT ANDNACTIIVEIWITH THE SCAL CALIFORNIA CONTRACTORS STATED ICEINSE BOARD AND O CETHAT I AMTIFY T LICENSE MY REQUIRED IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9530-7697p SIGNED !�r TITLE )D IPr DATE l!l�CI"lIJ_�+�-C O-� J fl I q ------------- ------------- ------------- ------------- ------------------- T C P AJRTMENT USE N L Y a'yRT,y�< ry N ale / C Area EmployeelD#� Application Accepted By ❑ ECIAL Well Permit Grout Inspection By Dale Pump Inspection By Date C1 WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS Amount Permit/ Invoice# Well ID# PE SC Recelved a Date Service Request# C as Info By Cash Remitted .1 __ 00 i IVj O cl}-1 lU} nJ� WELL/PUMP PERMIT EHD 43-00 9/01110