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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 i+ NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CITY/ZIP m D CROSS STREET 7T��w //�APN ` '�i 1 1 fy/V/ ARCEL SIZE LAND USE APPLICATION#) Q p OWNER NAME �LLL�ysi1�-Lo D t l V A i!! ��QV ,� y� -�PHONE2_y ��+C/I�'7 -7 v'�J97 y OWNER ADDRESS ��C/ f/� � i �i�_5 /L CITY/STATE/ZIP_�� Z� C��I !tJ / < CONTRACTOR PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE DOMESTIC WELL SAMPLING: I General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) i Arsenic(4393) INTENDED USEDomestic/Private LJIrrigation/Agricultural ❑ Industrial ElWater Quality Monitoring ElSoil Sampling/Characterization EJublic 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��#of borings ElEl111"'R Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair YAO�� New Pum ❑ Pum Re lacement ❑ Pum Re air ❑ Raise Well Casin r,/ WELL CONSTRUCTION ED Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other AD 4 Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gra ize 0&iameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft "Vi COU Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Stw Nek';4�_ Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement s9C Wfjjal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other 11 Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersible❑ Turbine ❑ Other HP 1,— Pump Set ft Standing Water Level ft I HEREBY CER IFY 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 ACTIV WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENS ION LAWS. MINIM 1ICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953- 697 _ SIGNED TITLE � /Gt �� I! �r' -`� � DATE (J P ARTMENT U E JDNLY -3113114? Application Accepted By Date Area Employee ID#A� Grout Inspection By Date ❑ SPECI L Well Permit Pump Inspection By �' )n) � `�'��'� Date o 2o�C� ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Permit/ Codes Inf B ash mitted Date Service R uest# Invoice# Well ID# EHD43-06 8/01/16 2 WELL/PUMP PERMIT