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CALL (209) 953 -7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED NON-REFUNDABLE PERMIT <br />WELL/PUMP PERMIT <br />- SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />JOB ADDRESS 5375 /A-,7/ ciTylzip <br />CROSS STREET AP N 6kc CqL) 6 i/PARCEL SIZE A LAND USE APPLICATION # <br />OWNER NAME VA a PHONE <br /> <br />CITY/STATE/ZIP <br />PHONE 3 - J I 2. <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />CONTRACTOR ADDRESS <br />X4.11 SUBCONTRACTOR <br />OWNER ADDRESS <br />CONTRACTOR A 4--A (7pacs. aitin <br />/73 <br />/ -(7; C;gose <br />LICENSE "...A:LC-57 Li 0-61 Li D-09 E Other NUMBER) 7 i& EXPIRATION DATE <br />CITY/STATE/ZIP <br />PHONE .7 3f - 71,5 — <br />0 <br />6 <br />IL <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392)1 Arsenic (4393) <br />INTENDED USE i›,ebomestic/Private 0 Irrigation/Agricultural Li Industrial II Water Quality Monitoring Li Soil Sampling/Characterization <br />Public Water System <br />Water System Name <br />TYPE OF WORK A New Well E Replacement Well Li Well Alteration/Modification Li Other <br />111 Monitoring Well(s) # of wells H Soil Boring(s) # of borings <br />Li Geotechnical <br />Out-Of-Service Well Li Out-Of-Service Well Renewal <br />›eNew Pump 0 Pump Replacement rl Pump Repair <br />WELL CONSTRUCTION <br />Drilling MethoMud Rotary <br />Proposed Well Depth .3 Z ) <br />Li Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 2.-2" Ii Steel 7-Plastic LI Stainless Steel E Other <br />Grout Seal DepthilQ- E Neat Cement (94 lb bag/5-10 gal water) .,-Sand Cement /4,/ A '7 <br />[l Bentonite (20% solids) U Other <br />Grout Placement Methodeo(Pumped Free Fall 11 Other 1 1 Retardant / Accelerator (name) <br />PEDESTAL Installed By ..e..Driller E Pump Contractor H Other <br />Concrete Pedestal EDimensions: Width 9 ft Length r ft Thick in LIChristy Box E Stove Pipe <br />e- ft ft Standing Water Level Pump Set )'Submersible Li Turbine 11 Other HP PUMP <br />! HEREBY CERTIFY THAT ! HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 8 jOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE (11-41•4"1" DATE <br />If different from Owner Contact Name or Phone Numib 4 yloil <br />0 Cross-Connection Repair Dke 2 7 2018 <br />L] Raise Well Casing SAN <br />1.4,.V/ROA,..7 <br />Li Air Rotary L] Auger Cable Tool Push Point Li Other -L-YiLTH NTAL r <br />h-P4N7-114E.r ft Excavation in diameter H Open Bottom )(Gravel Pack/Gravel Size tii _ diameter <br />sack mix/7 gal water :SS32ICICIV 311S DPARTMENT USE ONLY <br />Area Employee ID# <br />PECIAL Well Permit <br />III WAIVER Received <br />Constructed Well Depth <br /> ft <br />.46 <br />Application Accepted By Date <br />Grout Inspection By Utte\2\kil kfr"?t,Lit)\ Date I <br />Pump Inspection By V-itv6,6 Date t A-9 <br />Soil Boring InspsectioniBy Date <br />COMMENTS pai, 61- 2,6 0 <br />PE <br />Codes <br />SC <br />Info <br />Received cliiii?") <br />Cash <br />Amount Amount <br />Remitted Date Permit/ <br />Service Reowest # Invoice # Well ID# <br />OLi . ( SeD (.7? / 372 4 0 ,4 4 2-7 161 Ar3 OUYIPri <br />owl 051 1 3_72- -- 2-7-12/210 (g003`,11L-tY <br />I (1 <br />1*: .. r I ,S72-- (j.- 12/21 / la wp e03(41`17 <br />END 43-06 8/01/16 <br /> WELL /PUMP PERMIT