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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 Cf` CITY/ZIP m CROSS STREET D �'v�� APN �VQ PARCEL SIZE LAND USE APPLICATION# v OWNER NAME _ PHONE 6P� rlr'15Z v� OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR /Z� i )55 PHONE 7 CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑ C-57 ❑ C-61 U D-09 f! Other NUMBER EXPIRATION DATE DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural I Industrial Ll Water Quality Monitoring u Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK L New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings 11 Geotechnical #of borings ❑ Out-Of-Service Well I 1 Out-Of-Service Well Renewal Ll Cross-Connection Repair 11 New Pump eump Replacement I 1 Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger LI Cable Tool 1_1 Push Point IJ Other Proposed Well Depth ft Excavation in diameter (I Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched f 1 Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft 11 Neat Cement(94 lb bag/5-10 gal water) LI Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped I 1 Free Fall f 1 Other Il Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor I 1 Other Ll Concrete Pedestal Ll Dimensions:Width ft Length ft Thick in I I Christy Box I I Stove Pipe PUMP ubmersible 11 Turbine ❑ Other HP Pump Set ft Standing Water Level ft I HEREBY ERTIFY 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. MI 4 DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95,E-76 7 SIGNED �� 1,�Z— TITLE DATE All a AI C U TY N R NT D TH IC S DE�P AZTMENT U E O LY Application Accepted By Date Area44 Employee ID# Grout Inspection By 1 Date ❑ SPECIAL Well Permit Pump Inspection By falf:S W Date ISI lama* ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Cods Info IBV Cash Remitted Service Request# 5 EHD 43-06 8/01/16 WELL/PUMP PERMIT