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Area Employee ID# <br />Li PE IAL Well Permit <br />El WAIVER Received <br />Constructed Well Depth ft <br />WELL/PUMP PERMIT P - <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 />lc 3) Aik&—) CITY/ZIP <br />AP N 22-S --- t --01 PARCEL SIZE LAND USE APPLICATION # <br />\A) Ps tJick--4_(A1.1 1r eicti PHONE 21111 -2- 232- <br />2 v a <br /> <br />CONTRACTOR ADDRESS lSoczy a-2-oc,_A CITY/STATE/ZIP C-A 9 <br /> <br />SUBCONTRACTOR <br /> <br />PHONE <br /> <br />JOB ADDRESS <br />,I;t0SS STREET <br />bWNER NAME <br />,OWNER ADDRESS <br />CONTRACTOR <br />V . <br />CITY.STATE/ZiP q5-3•M <br />qC-. 512rioNE .70 —44 4- 267 <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE [7 C-57 0 C-61 E D-09 )/2ther ‘12A NUMBER JO I. 1.7q EXPIRATION DATE 7 3c <br />DOMESTIC WELL SAMPLING: n General Mineral/Coliform Bacteria (4391)11 Dibromochloropropane (4392) Li Arsenic (4393) <br />INTENDED USE LI Domestic/Private LI Irrigation/Agricultural U Industrial 1_1 Water Quality Monitoring Li Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />17 Other <br /># of wells El Soil Boring(s) # of borings <br />TYPE OF WORK C7 New Well E Replacement Well <br />Monitoring Well(s) <br />X Out-Of-Service Well <br />Cl New Pump 0 Pump Replacement <br />Li Well Alteration/Modification <br />LI # Geotechnical of borings <br />E Out-Of-Service Well Renewal E Cross-Connection Repair <br />E Pump Repair 11-1 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method CI Mud Rotary 0 Air Rotary Li Auger U Cable Tool E Push Point 0 Other <br />Proposed Well Depth ft Excavation in diameter Li Open Bottom Ei Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched LI Steel LI Plastic Li Stainless Steel 0 Other <br />Grout Seal Depth ft E Neat Cement (94 lb bag/5-10 gal water) Li Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) 0 Other <br />Grout Placement Method 0 Pumped Fl Free Fall E Other Fl Retardant / Accelerator (name) <br />PEDESTAL <br /> <br />Installed By Li Driller E Pump Contractor El Other <br />Concrete Pedestal UDimensions: Width ft Length ft Thick in LI Christy Box Li Stove Pipe <br />PUMP Submersible E Turbine E Other HP Pump Set ft Standing Water Level ft <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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 913-797 <br />><S.IGNED TITLE pp---0(31.-- 04-iN NAC=-L-12- DATE 11 let -1 I <br />13 7:01— 8 <br />cNr <br />411.P <br />:7 <br />eceivect <br />iztAANio---v cow/ picopmmzivrriAt rY <br />Eorr <br />E ARTMENT U E 0 LY <br />t <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS '0\1•5\, L34.c- - AgiS) Q.-0Q ic_A 1,-;\ 05) 51 <br />,<ee CapyrieYks <br />-\* <br />Date <br />Date <br />Date <br />Date <br /> :SS321CICIV 3119 rk- \N.) 1ç1/4-x- WrAt\-c A.33 c 04i 5 rF-- L 17-1- 6 NY-1 NJ- <br />PE <br />Codes, <br />SC <br />Info n <br />Received <br />By, <br />aheracitli Amount <br />33 emitted Date , i i i <br />Permit/ <br />Service Request # Invoice # Well ID# <br />Cash <br />Of rig _d&----. 3777 517/1 - _"Pi/lb'.(A)Pon2114v5 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT