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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 /�ae k nCALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED S 3Z �`e JOB ADDRESS A CITY/ZIP J"i2fG{LY'?J/.1 �Z m CROSS STREET � LaS� � APN lg/ 1 1D' 0 6� n PARCEL SIZE LAND USE APPLICATION# o OWNER NAME S4MM`! Cn')t. PHONE /�Q�� 77b I ren OWNER ADDRESS Pr e/t(I� l �I Z CITY/STATE/ZIP LiND�ii`j,(_A CONTRACTOR -7'1 J/J 1 f��i PHONE QJ6 I & --7'7�3/ CONTRACTOR ADDRESS Pu Ao�c �J 7 Z+ CITY/STATE/ZIP Llhl'L r:0%j 6A q5 L SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE I I C-57 1 I C-61 -1 D-09 1-1 Other A NUMBER / EXPIRATION DATE Q 31 / DOMESTIC WELL SAMPLING: I General Mineral/Coliform Bacteria (4391)❑ Dibromochloropropane(4392) 1 Arsenic(4393) INTENDED USE I I Domestic/Private ❑ Irrigation/Agricultural I I Industrial U Water Quality Monitoring ❑ Soil Sampling/Characterization I I Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK I I New Well ❑ Replacement Well I I Well Alteration/Modification I I Other I Monitoring Well(s) #of wells I-I Soil Boring(s) #of borings I 1 Geotechnical DENT vKut-Of-Service Well I I Out-Of-Service Well Renewal CI Cross-Connection Repair RECEIVED I I New Pump ❑ Pump Replacement I I Pump Repair I Raise Well Casing WELL CONSTRUCTION JUN 2 0 1019 Drilling Method I I Mud Rotary f I Air Rotary (i Auger 1 Cable Tool I I Push Point I I Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Si�6AN JOAQUINrLcknoltyr I I Conductor Casing in diameter / Conductor Casing Depth ft -NVIRONMENTAL HEALTH DEPARTMENT Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel -1 Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) 1 I Sand Cement sack mix/7 gal water I I Bentonite(20%solids) ❑ Other Grout Placement Method I I Pumped ❑ Free Fall I 1 Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other I I Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box 1-I Stove Pipe PUMP Submersible[] Turbine 11 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. MINIMU 8 HOU VANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 953-7697 SIGNED TITLE DATE I. -I. 2 L 49 , M T v P YRTMENT U E ONLY Application Accepted By Date l Area t Employee ID# Grout Inspection By Date ❑ PECIAL Well Permit Pump Inspection By Date FI WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS 5 Tn N our-c>�--Sracv4Ce.' WE'\I (� �.cmt,\ r� cAter� Otr y. v Nicl'y'r)K� PE Sc Received Ch Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request F-H EHD 43-06 8/01/16 WELL/PUMP PERMIT