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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 JOB ADDRESS JAto/-A Xe-1 CITY/ZIP �1f7��f'�% 1 14 �/�G_"7(� m //bb D CROSS STREET �� +n /fir✓ APN 40� "�40 7^"/ PARCEL SIZE(7' LAND USE APPL�ICATIONN#-7+ ,s 0 OWNER NAME L G' PHONE ��f'/ clf)S` —1 SJ (n OWNER ADDRESS r") z'j/ ��))!/?Al e", CITY/STATE/ZIP CONTRACTOR \ 3/f'7 //7 C PHONE 2e- ` 112 -z7 7 7 CONTRACTOR ADDRESS ? /%7�L,1�,--<h �� CITY/STATE/ZIP �r- SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP S LICENSE 9C-57 ❑C-61 ❑D-09 ❑Other NUMBER.";?Z, ,'�Tj EXPIRATION DATE' DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)[-]Arsenic(4393) INTENDED USE Xbomestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring El Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ]New Well E]Replacement Well ❑Well Alteration/Modification El Other ❑Monitoring Well(s) #of wells [-]Soil Boring(s) #of borings #of borings ❑Geotechnical F]Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing WELL CONSTRUCTION Drilling Method Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other Proposed Well Depth 3"6:C7 ft Excavation 1Z !6e in diameter El Open Bottom AlGravel Pack/Gravel Size in diameter F-1 Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_(eL,- in Thickness/Gauge/ASTM Sched P 2 t ❑Steel Plastic El Stainless Steel E]Other Grout Seal Depth &0 ft ❑Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement /�f ,�i sack mix/7 gal water ❑Bentonite(20%solids) F1 Other Grout Placement Method Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By Wriller ❑Pump Contractor ❑ Other [-]Concrete Pedestal dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP 5d Submersible❑Turbine ❑Other HP Pump Set <'Cy c 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 OUR AD VA OTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED TITLE �- /C �'r�r'�'CLQ ij� DATE AN D T F EP RTMENT U E JQNLY Application Accepted By Date Area Employee ID# 1 Grout Inspection By Date ' / ❑ SPEC AL Well Permit Pump Inspection By ;6LfA, n„� ,ti Date 1 11 w ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS 64;hi/i PE Sc Receivedheck#/ Amount Permit/ Codes Info B Cash a fitted Date Service Request# Invoice# Well ID# o a I , V+ ' t f2�fr EHD 43-06 8/01/16 WELL/PUMP PERMIT