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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 NON-REFjjNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED Rn- CITY/ZIP m 'n D CROSS STREET r APN - PARCEL SIZE 1 Sl LAND USE APPLICATION# �- A -4-- m OWNER NAME i PHONE m OWNER ADDRESS CITY/STATE/71P L CONTRACTOR \ PHONE M A CONTRACTOR ADDRESS�G Tr�cf� yY�6y l C l�\ W I mG CITY/STATE/ZIPST SUBCONTRACTOR/CONSULTANT bLE 1 1\ r� JJ PHCO-CN'' (I IL, r y- U1 SUBCONTRACTOR/CONSULTANTADunesS 1 O CITY/STATE/ZIP LICENSE V"*"7 ❑C-61 Cl D-09 ❑Other NUMBER101'al _ EXPIRATION DATE BILLING PARTY: ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING:D General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)D Arsenic(4393) INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑ Industrial ❑Water Quality Monitoring oil Sampling/Characterization ❑Public Water System If different from Omer. Water System Name Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other # ❑Monitoring Well(s) #of wells ❑Soil Boring #of borings s) Geotechnical of borings ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair ❑New Pum ❑Pump Replacement 7 Pump Repair C Raise Well Casing WELL CONSTRUCTION C�r 1 L Drilling Method Mud Rotary C Air Rotary Auger ❑Cable Tool 6/Push Point C Other c CI V Proposed Well Depth ft Excavation in diameter C Open Bottom ❑Gravel Pack/Gravel Size in diamet � 1 I I Conductor Casing in diameter / Conductor Casing Depth ft V IJ 20 1,G Well Casing Diameter in T�ickness/Gauge/ASTM Sched :1 Steel 7 Plastic ❑Stainless Steel ❑Other Grout Seal Depth N eat Cement(94 Ib bag/5-10 gal water) -1 Sand Cement Sack mix/7 gal AQ(/ ❑Benton' 270%solids) C other RpNMENTU/.rry Grout Placement Method dumped C Free Fall Other C Retardant I Accelerator(name) nLrr DEp' N A/_ PEDESTAL Installed By ❑Driller ❑Pump Contractor 7 Other u Concrete Pedestal UDimensions:Width ft Length ft Thick in L Christy Box L Stove Pipe PUMP I I Submersible I Turbine i 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. MINIMN 448 HOUR ADVANCE NOTICE REQUIRED FOR �ny INSP(r�CTIONGS-PLEASE CALL(209)953-769`7 SIGNED /.•'�'iF`A`' ~- � TITLEOLTI �lyVC Y DATE ! EP RTMENT U E PINLY Application Accepted B , Date Area Employee Grout Inspection By Date ❑ SP CIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By �Qg Inspection By Date Constructed Well Depth ftWell Depth ft COMMENTS PE Sc Received Check#/ Amount Permit/odes Info B Cas Remitted. D to Service Re uest# Invoice# Well ID# tV EHD 43-06 6/11/2079 �/� /�/��/ �T � WELL/PUMP PERMIT