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rN ,s WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 NON-REFUNDABLE PERMIT !' WWW.S Ov.OT /ehd /EX/PIIRREES1 YEAR FROM DATE ISSUED 101) Jos ADDRESS �J �/ 1� I^ CITY/ZIP�a�1dA CROSS STREET Alj Qll.01 Wu� A�Py1IN �C 1�v�/DO PARCEL SQE r I t LAND USE APP1PLLIICATIO'N�# 2/ �j� OWNER NAME AVG 1�D^ A V�ZQ/V�I✓w)p PHONE�l I.v�t��aab�[J OWNER ADDRESS JJ//([ 'tel rl.r 1•V CrrYISTATE/ZIP CONTRACTOR l i +ie Mai If L�L(/f�I AL PHONE . /D� CONTRACTOR ADDRESS O V�G Y L'1 CnY/STATE/ZIP J—c3 (97 SUBCONTRACTOR/CONSULTANT I PHONE SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP q LICENSE x C-57 C-61 D-09 Other NUMBER ID(-103 EXPIRATION DATE BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTORICONSULTANT DOMESTIC WELL SAMPLING:A General Mineral/Coliform Bacteria(4391)it Dibromochloropropane(4392) Arsenic(4393) INTENDED USE XDomesbc/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK XNew Well Replacement Well Well Alteration/Modification Other Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of borings Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair New Pump Pump Replacement Pump Repair Raise Well Casing WELL CONSTRUCTION Drilling Method'/V,Mud Rotary Air Rotary Auger Cable Tool Push Point Other Proposed Well Depth ft Excavation [:;�,—in diameter Open Bottom /N Gravel Pack/Gravel Size in diameter Conduct in diameter I Conductor Casing Depth ft Well Casing Diameter n Thickness/Gauge/ASTM Sche Steel A Plastic Stainless Steel Other Grout Seal Depth ft Neat Cement(94 lb bag6-10 gal water) Sand Cement sack mixg gal water �(Bentonite(20%solids) Other Grout Placement_Method umped Free Fall Other Retardant/Accelerator(name) PEDESTAL Installed By Driller Pump Contractor Other Concrete Pedestal Dimensions:Width It Length ft Thick in Christy Box Stove Pipe PUMP Submersible Turbine Other HP Pump Set It 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. 1 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. MINIMU UR/'p/�n(`VANCE NOTICE REQUIRED FOR 1IN§PE'C,T/IONS-PLEASE CALL(209)953-7697 SIGNED / TITLE Z Y l ll l"✓4' DATE MFN�, 01 14Y 44 SFO OO 0�ry MFNr DEPARTMENT USE ONLY Application Accepted By �� Date Area Employee ID#� Grout Inspection By Date 2( SPECIAL Well Permit Pump Inspection By Date WAIVER Received Soil Boring Insp cti n By Date Constructed Well Depth COMMENTS Si or wwa I-t-Inea. Ass or Ll -/ a;