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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 ``,,CEEALL 209 953-7697 FOR INSPECTIONS i�EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS M4-6 Vv 2 D CITY/ZIP %0"L 2 f.% m CROSS STREET i 'Pk'-)J vac s APN I D�U 1 PARCEL SIZE` � � LAND USE APPLICATION# m OWNER NAME �C U IK f l/� L / hhPHONE A -1,a2y OWNER ADDRESS 4 V CITY/STATE/ZIP K.I " CONTRACTOR b �'l ( V (I 1 d �P�HO�N/E��a QCI �7 tgA •Vl `1 /�7� CONTRACTOR ADDRESS 1 V ,n —1—1 ll/ CITY/STATE/ZIP?I 't �'�� SUBCONTRACTOR Y 1 PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER I LL#4 OP EXPIRATION DATE rj I Z� DOMESTIC WELL SAMPLING: eneral Mineral/Coliform Bacteria (4391) ibromochloropropane(4392) Arsenic(4393) INTENDED USE JomestOPrivate XIrrigation/Agricultural II Industrial ❑ Water Quality Monitoring Cl Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK XNew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical Ivej; 'sg ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair �l® [I New Pum 11 Pump Replacement F1 Pump Repair 11 Raise Well Casingoli WELL CONSTRUCTION SANJ 9 Drilling Method Mud Rotary 11 Air Rotary [I Auger 11 Cable Tool 11 Push Point 11N Other FP Em,- IV Proposed Well Depthjj OD ft Excavation 1 in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel_S-3XI/ Ti�dla eter ❑ Conductor Casing in diameter / Cond ctor Casing Depth ft MENT Well Casing Diameter� in Thickness/Gauge/ASTM Sched' �2J ❑ Steel ;h Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth_�a_ _ft ❑ Neat Cement(94 lb 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 El Dimensions: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. MINIM M R VANCE OTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697` SIGNED TITLE � DATE O y CA M N '�• Tly EE I 1 1 1 DEPARTMENT USE NLY Application Accepted By _ Date l ` Area ' � Employee ID#�� Grout Inspection By Date �1 �'1� 1p1 ❑VPECIALl ePermit Pump Inspection By I, Date ❑ WAIVER Received Soil Boring Insp ction By Date Constructed Well Depth ft COMMENTS IF ra PE SC Received hec Amount Permit/ Invoice# Well ID# Codes Info By Cash Remitted / Service Request# EHD 43-06 8/01/16 WELL/PUMP PERMIT