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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAs-r HAZELTON AVENUE - STOCKTON CA 95205 • (209) 468-3420 <br />JOB ADDRESS 28150 SoAcs (A. c,,,,p (a4 ciL, 3 2_ <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />CROSS STREET APN 001/1 XL() PARCEL SIZE 2 2. tilLAND USE APPLICATION # <br />OWNER NAME a110 Nioeyards, knc. PHONE loot - 3911- (9200 <br />cmdsTATEizip LVI JIVE) n C P ci 5339 OWNER ADDRESS 59 53 NI. VA-e% <br />CONTRACTOR là ear° Pn PHONE 209 - (932 -31to) <br />cirwsTATEizi, i-k s 00 C c16326 CONTRACTOR ADDRESS VO31aX 03'6 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE X C-57 E C-61 0 D-09 C Other NUMBER .7115_9k,3_ EXPIRATION DATE 3/ 31/ 2.01g <br />DOMESTIC WELL SAMPLING: General Mineral/Coldbrm Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE = Domestic/Private IrrEg iltural E Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK D New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />7 Monitoring Well(s) <br />e <br />So/wells 0 Soil Boring(s) # of borings 0 Geotechnical /I of borings <br />)t/Out-Of-Service Well \J"'R. 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />7, New Pump 3 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Li Mud Rotary P Air Rotary n Auger n Cable Tool n Push Point 0 Other <br />Proposed Well Depth It Excavation in diameter C Open Bottom 0 Gravel Pack/Gravel Size in diameter <br />3 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel ri Other <br />sack miter7 gal water Grout Seal Depth ft 0 Neat Cement (94/b bag/5-10 gal water) 0 Sand Cement <br />Li Bentonite (20% solids) 0 Other <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant / Accelerator (name) <br />SIGNED <br />PEDESTAL Installed By LI Driller 0 Pump Contractor Li Other <br />° Concrete Pedestal DDImensions: Width ft Length ft Thick In II Christy Box 0 Stove Pipe <br />It Pump Set ft Standing Water Level 0 Submersible° Turbine 0 Other HP PuMP <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 />MINI 0 R AD j NCE NOTICE REQUIRED FOR INSPECTIONS • PLEASE CALL (209) 953-7697 <br />TITLE Senor Y)VeCbr GM-CV DATE 12-3 I24 g <br />Ji <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By Date <br /> <br />Grout Inspection By Date <br /> <br />Pump Inspection By Date <br /> <br />Soil Boring Inspection By <br /> Date <br />COMMENTS \, <br />Area L f/1.) Employee IWO A h old <br />0 SPECIAL Well Permit <br />0 WAIVER Received <br />Constructed Well Depth ft <br />Q -51 d\ k <br />PE <br />Codes <br />SC <br />Into <br />Received CFCte Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well IN <br />/7,57(3l il )---- :-Itc-)1 ty <br />END 43-06 8/01/16 WELL PUMP PERMIT