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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 / �1 e(7 � /��/L��C " /`� CITY/ZIP L//t� � In JOB ADDRESS In CROSS STREET /7/y SIC/,4-/--.* APN PARCEL SIZE�LAND USE APPLICATION# In A l 1` If En OWNER NAME `'^' /� &/`C/K ' PHONE y OWNER ADDRESS �/"'It cf- l CITY/STATE/ZIP s� CONTRACTOR A�ff��A y� °7N�).A�S (//�L�6 ' PHONE U �� CONTRACTOR ADDRESS A /s� [-7 L? CITY/STATE/ZIP �f/SIJ SUBCONTRACTOR I`G`tT� .�3 '�� PHONE 1'-)' SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE DOMESTIC WELL SAMPLING: i i General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) i i Arsenic(4393) INTENDED USE ❑ Domestic/Private I"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 ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ,*:Mew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION 20/9 Drilling Methodj::�Mud Rotary LlAir Rotary 11Auger EICable Tool 11Push Point 11Other SAN JOA Proposed Well Depthi—IJ02 ft Excavation in diameter ❑ Open Bottom ><Gravel Pack/Graa�iVIR Nu F U?Nmeter ❑ Conductor Casing _in diameter / Conductor Casing Depth ft ARrMENT Well Casing Diameter-?— in L)in Thickness/Gauge/ASTM Sched] _ Steel �Iastic ❑ Stainless Steel ❑ Other Grout Seal Depth 5:) ft ❑ Neat Cement(94 lb bag/5-10 gal water) >U Sand Cement It�� _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 j� Ll Other ❑ Concrete Pedestal ❑Dimensions:Width—Z ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersible❑ Turbine CI Other HP 1 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. MINIMPM,488 HOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) /953-7697 SIGNED TITLE DATE L 9 V 01- DE AR MENT US,E ON/ Y Application Accepted By Date h 4 ! Area hol Employee ID# Grout Inspection By Date -) 1,2 lei I L� SPECIAL Well Permit Pump Inspection By Date k3L yr, L7 WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMM TS 0O31&6 6111,7 ra4i i— x 0 PE SC Received ec Amount Permit/Codes Info s e Date Service Re uest# Invoice# Well ID# EHD 43-06 8/01/16 WELL/PUMP PERMIT