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• WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NUN -REFUNDABLE gPERMIT K GALL ZU9 953-7697 FOR INSPECTIONS �`yEX`PIIRLb 1 YEAR FROM UATE ISSUED JOB ADDRESS I 1 `� ` d f1spn hic CITY/ZIP J�1 ^j-- �--'A 9S2 -j5 CROSS STREET �A-',] -``.. APN OS'Oq 1 - 000 PARCEL SIZEd.220 LAND USECA�PPLIICCATI'O�N/#{ OWNER NAME 1•�Qcr,Cr�sAt iP0k6ACCO PHONE CIS OIC OWNER ADDRESS ��A7J� 1 -C rm^, q Ave- CITY/STATE/ZIP 'S+OG k_f1-V '1� ICq ar s CONTRACTOR I .lAS'C�1 i c 1 �'�1 ��L� PHONE SLG' C � —9 CONTRACTOR ADDRESS 1 g n $ J ad • CITY/STATE/ZIP / LilOt es/a , CR q53.5`7 SUBCONTRACTOR SUBCONTRACTOR ADDRESS LICENSE xC-57 C-61 ❑ D-09 ❑ Other. PHONE CITY/STATE/ZIP NUMBER 410%2-2— EXPIRATION DATE �Y_31-2-1 DOMESTIC _2 - DOMESTIC WELL SAMPLING: 1 General Mineral/Coliform Bacteria (4391) CI Dibromochloropropane (4392) ❑ Arsenic (4393) INTENDED USE Domestic/Private Irrigation/Agricultural I Industrial ❑ Water Quality Monitoring I Soil Sampling/Characterization Public Water If different from Water System Name Contact Name or i1pE�lr1VORK New Well replacement Well ❑ Well Alteration/Modification I Other " a� I� ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings I I Geotechnical #p eof borings ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal I i Cross -Connection Repair S ry / I ?04� F] New Pump I Pump Replacement ❑ Pump Repair 1 Raise Well Casing AN Jnr_ I LL STRUCTION HSL V/R_"M COUN7 Ili ethod�Mud Rotary Air Rotary I I Auger i I Cable Tool I Push Point I I Other TNOE ENTAN p Well Depth 2 S 0 ft Excavation t 2 in diameter ❑ Open Bottom Xj Gravel Pack/Gravel Size inE�meter Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Schad ❑Steel lastic Stainless Steel Other Grout Seal Depth td O ft ❑ Neat Cement (94 Ib bag15-10 gal water) Sand Cement sack mix/7 gal water Bentonite (20% solids) ❑ Other Grout Placement Method XPumped ❑ Free Fall 1 ! Other 11 Retardant / Accelerator (name) PEDESTAL Installed By -I Driller Xpump Contractor 1 Other 1 i Concrete Pedestal f_IDimensions: Width ft Length ft Thick in I I Christy Box I I Stove Pipe PUMP 1 1 Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY 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. L1�QUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSP CTIONS - PLEASE CALL (209)) 9533--7697 eb SIGNED TITLE rl 1 e A/ A.� ,� . ^�_ DATE G'�9 EPARTIMENT Grout Inspection By Area /( Employee ID# 5.1 SPECIAL Well Permit Pump Inspection By Date 1,WAIVER Received Soil Boring Inspection By COMMENTS vre.' C)6 - 4;s i.��ek 106' 460..-k� Date Constructed Well Depth ft T m D v v m m W 11� EHD 43-06 8/01/16 WELL /PUMP PERMIT Service Request # cw�l EVEN ME Nowlin -�� _� t D►11 U 1 EHD 43-06 8/01/16 WELL /PUMP PERMIT