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k"n I L- APP10 1J6'10 Pj2i4t i TL' M /UM ef @ WPC4 WELL/PUMP PERMIT SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HA7ELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 NON-REFUNDABLE PERMIT � L�www.si cy.orq/ehd — EXPIRES 11 YEAR FROM DATE ISSUED JOB ADDRESS BWP. MV L MyI Q�/moi l✓Lr� 4D- CITY/ZIP AP&P,rot/v MGW L` /2✓�L� m /�v"ter f�,�( �L/y S D CROSS STREETk�e�113 , �ZI� AF'N Z 7 �U-'S 7 Q PARCEL SIZE,-LAND USE APPLICATION# O OWNER NAME A-�O ' CL 41 LLC d / ,TA 0/6-31- ��QN / PHONE f�_g/f/ g y J�jO N OWNER ADDRESS DDII llW . &D 6P 10,-y _ � �i' Cl CITY/STATE/ZIP&A-41 /'�ew'Y te�e//t 90 a d CONTRACTOR _ W D� 1 L�'1��1,_; �WC• PHONE Zo y- T6 / — CONTRACTOR ADDRESS_1133 ani*L KLM V t2j( P,,2—y� C �q CITY/STATE/ZIP_ QC 4 9Sb3 (/ SUBCONTRACTOR/CONSULTANT w il'i'A L G'��U ( / /Ir JJDd 'I PHONE //6^3A��,1)3/2, SUBCONTRACTO /CONSULTANT ADDRESS 365b 1POVS t QI ill, $44W. CITY/STATE/,Z`IP W L' ( S/kG2 A(/N��L�f L v 6` LICENSE -57 ❑ C-61 ❑ D-09 1.1 Other NUMBER v EXPIRATION DATE_ r 13�'l��Z BILLING PARTY:S l OWNER CONTRACTOR USCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING:' I General Mineral/Coliform Bacteria(4391)n Dibromochloropropane(4392) Arsenic(4393) [LNENDEDUSE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring Xsoil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well D Replacement Well 0 Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells Soil Boring(s)- #of borings Geotechnical of borings ❑ Out-Of-Service Well ii Out-Of-ServiceeIW I Renewal ❑ Cross-Connection Repair ❑ New Pump 0 Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary/ ❑ Air Rotary Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth CMS Excavation 10 f/ in diameter ❑ Open qB ttom ❑ Gravel Pack/Gravel Size in diameter ❑ Conduct r Casing-W1 6 in diameter / Conductorasing Depth Well Casing DiameleN in Thickness/G ugelASTM SchedLi Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft feat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mixl7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method Cl Pumped XFree FallOther ❑ Retardant/Accelerator(name) ` JEEDEsTALp Installed By ❑ Driller ❑ Pump Contractor 11Other vim, �❑ Concrete Pedestal❑Dimensions:Width ft Length it Thick in ❑ Christy Box ❑ Stove Pipe LUMP n u Submersible[-/ Turbine ❑ Other HP Pump Set it 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 48 HOURAqVANCE NOTICE REQUIRED FOR INStP—ECTIONS/p-PLEASE CALL(209)95 -769 SIGNED TITLE 4y eJ e Cr CM6I NSG DATE 1 ��/Zd _ ✓ C 1 1 1+ 1 A-1--L E T EPARTMENT US ONLY q9 Application Accepted By _ ji Date AM Lxl Area / r Employee ID#��K°L Grout Inspection By Date SPECIAL Well Permit Pump Inspection By Date _ WAIVER Received Soil Boring Inspection By _ Date Z Dz J Constructed Well Depth _ ft COMMENTS PE SC ReceivedCheck Amount Permit/ Date Invoice# Well ID# Codes Info Bv Remitted Servide Request# — EHD 43-06 6/11/2015 WELL/PUMP PERMIT