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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 2-G-712— CITY/ZIP GV m 1 CROSS STREET S[cy�;ii I p(' �Jt�, � - ,guo APN PARCEL SIZE LAND USE APPLICATION# o 0 1 ' DIN . lg� y OOWNER NAME U'-- 10 P1 OWNER ADDRESS2-[5-712-r WNW CITY/STATE/ZIP �1 �I V rf qg 7� N CONTRACTOR J I 'NO PHONE n � 1�2,2-- 141,r�� CONTRACTOR ADDRESS CITYISTATElZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATEIZIP LICENSE C-57 ❑ C-61 CI D-09 i 1 Other NUMBER M,q !/ EXPIRATION DATE DOMESTIC WELL SAMPLING:AGeneral Mineral/Coliform Bacteria(4391) Dibromochloropropane (4392), , Arsenic(4393) INTENDED USE omestic/Private .I Irrigation/Agricultural it Industrial _] Water Quality Monitoring ❑ Soil Sampling/Characterization C Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORKNew Well ''I Replacement Well D Well Alteration/Modification 0 Other `Monitonng Well(s) #of wells ❑ Soil Boring(s) #of borings D Geotechnical #of boring s Out-Of-Service Well ❑ Out-Of-Service Well Renewal 0 Cross-Connection Repair _ New Pump i Pump Replacement I I Pump Repair I Raise Well Casing WELL CONSTRUCTION Drilling Methodvlud Rota Air Rotary U Auger Cable Tool t.1 Push Point Fl Other X// `` V Proposed Well Depth _ft Excavation in diameter a Open Bottom I�Gravel Pack/Gravel Siz in diameter Conductor Casing in diameter / Conductor C sing Depth 1` It Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel Plastic ❑ Stainless Steel a Other Grout Seal Depth_ 6 ft ❑ Neat Cement(94 Ib bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water Bentonite(20%solids) ❑ Other Grout Placement ethod Pumped 1 Free Fall ❑ Other A Retardant/Accelerator(name) PEDESTAL Installed By 0 Driller C Pump Contractor 0 Other I Concrete Pedestal ODimensions:Width ft Length ft Thick in Fl Christy Box I! Stove Pipe PUMP_ Submersible0 Turbine 0 Other HP Pump Set ft Standing Water Level " I 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. MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED F t INSPECTIONS -PLEASE CALL (209953-7 9 SIGNED <z TITLE \ Nt1 DATE�11J I -- Q 'IfAfN N � R DEPARTMENT USE ONLY Application Accepted 6y rr�L�` Date ,90 Area Employee ID# jK Grout Inspection By W wY S_� (e , Date ( i IaS��L C: SPECIAL Well Permit Pump Inspection By Date WAIVER Received Soil Boring Inspection By Date Constructed Well Depth 3(7�i ft COMMENTS r o,, I CE PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info By as Remitted Service Re uest# 66 l 3� j q:-- L7+14,) 0) -1 w C A 7 L 'Zl. 1 END 43-00 8/01118 YJELL/PUMP PERMIT &x,.