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CI Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />Well Casing <br />Grout Seal <br />WELL CONSTRUCTION <br />Drilling Method CI Mud Rotary El Air Rotary LI Auger 0 Cable Tool LI Push Point U Other <br />Proposed Well Depth ft Excavation in diameter LI Open Bottom CI Gravel Pack/Gravel Size in diameter <br />Li Conductor Casing in diameter / Conductor Casing Depth ft <br />Diameter in Thickness/Gauge/ASTM Sched Li Steel II Plastic E Stainless Steel Li Other <br />Depth ft LI Neat Cement (94 lb bag/5-10 gal water) Li Sand Cement sack mixI7 gal water <br />CI Bentonite (20% solids) E Other <br />I I Retardant / Accelerator (name) Grout Placement Method II Pumped LI Free Fall C1 Other <br />PEDESTAL Installed By rl Driller III Pump Contractor LI Other <br />0 Concrete Pedestal DDimensions: Width <br /> <br />ft Length <br /> ft Thick <br /> <br />in E Christy Box ii Stove Pipe <br />PUMP SubmersibleD Turbine U Other HP <br /> Pump Set <br /> ft Standing Water Level <br /> <br />ft <br />Li 7 <br />••••••• .M=0 0 <br />k Ls:\ SiLit9 <br />S.Frv 0 14.4 <br />NV' <br />See_ C/3/7011114S <br />Date <br />Date <br />Date <br />Date <br />WELL/PUMP PERMIT <br />SAN :JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />CITY/ZIP 93---2/3-/770 <br />. CITY/STATE/ZIP StO C-Afes A2 25-2/3-R-76 <br />PHONE <br />/114:14/ 7krt <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />m A rpc1;5 4 <br />S ;fry 1074- <br />11,g6 <br />C /- (oil) i<5 COAlcfrfL4C.1e1,d <br />r 613 C rp 6,0-1 <br />APN / 79 —05-e, PARCEL SIZE(, -21.- LAND USE APPLICATION # / <br />PHONE <br />12 el <br />CONTRACTOR ADDRESS ADDRESS f- et- p r ;S-e. CITY/STATE/ZIP <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE D C-57 D C-61 LI D-09 L] Other 8 I <br />NUMBER 705-22 EXPIRATION DATE 9-3049 <br />DOMESTIC WELL SAMPLING: I General Mineral/Coliform Bacteria (4391)11 Dibromochloropropane (4392) 'Arsenic (4393) <br />INTENDED USE Li Domestic/Private L1 Irrigation/Agricultural lit Industrial <br /> LI Water Quality Monitoring D Soil Sampling/Characterization <br />FA Well Alteration/Modification TYPE OF WORK 0 New Well E Replacement Well <br />Monitoring Well(s) <br />.New Pump fl Pump Replacement D Pump <br />E Out-Of-ServiceRepair Well Renewal J Out-Of-Service Well <br /># of wells CI Soil Boring(s) # of <br />I HEREBY CERTIFY THAT I 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 />SIGNED <br />MINIMUM 24 HOUR VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> TITLE COAPi e. /**- DATE ,42-5---17 <br />E Other <br />borings <br />Geotechnical <br /> # of borings <br />0 Cross-Connection Repair <br />Li Raise Well Casing :SS3ICICIV 31.19 Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS ..\> <br />DEPARTMENT USE ONLY <br />Li ECIAL Well Permit <br />LI WAIVER Received <br />Constructed Well Depth <br />C) c CZA)S--c)c- ) I`\ 9 ci_est-t-AA)-\ 0‘.x1c <br />Area Glji\ Employee ID# <br /> <br />ft <br />PE <br />Codes <br />SC <br />Info_ <br />Received <br />B <br />Check#L, <br />Cash 1')k-- <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# <br />444 e. 'Ilia. • 417.2c — limn w1200»ltii q <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT