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WELL/PUMP PERMIT S,4N 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 Ln JOB ADDRESS 1 R 'AvIS A I I-en CITY/ZIP 1L 1 po h /✓3 m /136- D CROSS STREET`oar 01 r APN 245-3 X4/0 PARCEL SIZE� AND USE APPLICATION# 0 ��^^ ` ��SZ' N OWNER NAME Lj U1, 1 � ''P�Y� �N�b �n (11�Q PHONECO) OWNER ADDRESS �S W'I\G 1`41 0 t Cl� CITY/STATE/ZIP/3eRc4l CONTRACTOR )'Apse I I i r t-' ffi'j Q::Ic, PHONE 52Z" t q2,g CONTRACTOR ADDRESS l 16- -S fU CITY/STATE/ZIP p d�I box eo�r da;0 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP 7 LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE DOMESTIC WELL SAMPLING: ❑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 ElReplacement Well ❑ Well Alteration/Modification ❑ Other 11 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method )(Mud Rotary ❑ Air Rotary ❑ Auger ❑ triple Tool ❑ Push Point 11 Other - in diameter ❑ Open Bottom Gravel Pack/Gravel Size in diameter Proposed Well Depth ?,60 Excavation ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter fo ii Thickness/Gauge/ASTM Sched 2-OV ❑ Steel TN Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth 20`' ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑3entonite(20%solids) ❑ Other Grout Placement Method Xumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ump Contractor ❑ Other ❑ Concrete Pedestal ❑Di ensions:Width ft Length ft 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. MI JM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209))953-76979 SIGNED —�- TITLE Cr A.Y1d DATE 1, -------- - - -------- --- -------------- --Z ------------ ------- Cl A i s 9 I C D q a IV- ------------------- f T DE ARTMENT USE 9NLY Application Accepted By Date ( Area Employee ID#A6%1 Grout Inspection ByAtaa,-- Date Q ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS �= �AAYIAfIdAA g 6S 4-,t LN !C U" PE SC Received h Amount Date Permit/ Invoice# Well ID# Codes Info By Cash Remitted Service Request# -o WELL/PUMP PERMIT EHD 43-06 8/01/16