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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 / v v L CITY/ZIP m �J D CROSS STREET LL APND / PARCEL SIZE LAND USE APPLICATION# S OWNER NAME Z U PHONE OWNER ADDRESS %V CITY/STATE/ZIP CONTRACTOR AM Coos3 /'PHHOANE� j�L�✓ L �� CONTRACTOR ADDRESS / Vy r�t�0"�' L�� Q CITY/STATE/ZIP `�VK%IIPJ' 4�j,Z SUBCONTRACTOR L/'N �f�A� r"� PHONE ,Z?—3 12.1 SUBCONTRACTOR ADDRESS CITY/STATE/ZIP / LICENSE J<C-57 11C-61 11D-09 CI Other NUMBER 37-2 i]Rf EXPIRATION DATE L� DOMESTIC WELL.SAMPLING: I i General Mineral/Coliform Bacteria(439 1) I Dibromochloropropane(4392) I Arsenic(4393) INTENDED USE omestic/Private ❑ Irrigation/Agricultural J Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORKQew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other /❑ Monitoring Well(s) #of wells El Soil Boring(s) #of borings F1 Geotechnical��j#of bo �® IJ Out-Of-Service Well [j Out-Of-Service Well Renewal 11 Cross-Connection Repair ^'N� ®� ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTIONH Flys/R4�1HC Drilling Method�ilud Rotary El Air Rotary ❑ Auger Ll Cable Tool F1 Push Point ❑ Other Ty ME �y Proposed Well Depth Z0 ft Excavation 1) in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size T�/ rneter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter 1C_ in Thickness/Gauge/ASTM Sched :2 '20 ❑ Steel 4PIastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft F1 Neat Cement(941b bag/5-10 gal water) [(Sand Cement 10._3 —sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method`Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) • PEDESTAL Installed Byruler ❑ Pump Contractor ❑ Other 11Concrete Pedestal Ll Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe ' PUMP Submersible[] Turbine 0 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. 1 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. MINIMUM HO4R AD ANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 9953-77697 SIGNED ` .� TITLE �(,c�il,ttJ DATE EP RTMENT US � QNLY Application Accepted By Date Area Employee ID# Grout Inspection By Date t ❑ SPECIAL Well Permit Pump Inspection By f,rN,%�Or L Date a ❑ WAIVER R@C@IV@d Soil Boring Inspection By Date Constructed Well Depth ft J COMMENTS�I j/�4 (4)K� 1A� 1� PE SC Received hec Amount Date Permit/ Invoice# Well ID# Codep, Isfo Remitted Service Request# /n 4MY 1W-7 Z r EHD 43-06 8101/16 WELL/PUMP PERMIT