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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS ZjJ/`(/ S /fa y 'eelCITY/ZIP (i/r/n�/lh efa �SZZ 7 rn k D CROSS STREET �T/�/�S /CG/ APN 011-330-01 3 PARCEL SIZE (1 LAND USE APPLICATION# o m OWNER NAME �� 6� PHONE 11k &/-3 ZDSS/ rCn n OWNER ADDRESS lg,�r%d 4 P,,,nC/CO rfjQ CITY/STATE/ZIP 1 / 05217V CONTRACTOR A'3' f Zell&*//JC '/PHONE CONTRACTOR ADDRESS o�� I�Z 9 CITY/STATE/ZIPy/_'Z&evJ SUBCONTRACTOR _ PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP e LICENSE ;XC-57 ❑C-61 ❑D-09 [_1 Other NUMBER ZD/707O EXPIRATION DATE CJ -4.1 XzOZZ DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE �Xbomestic/Private ❑Irrigation/Agricultural ❑Industrial El Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name uontact Name or Phone Number TYPE OF WORK flew Well ❑Replacement Well ❑Well Alteration/Modification E]Other ❑Monitoring Well(s) #of wells ❑Soil Boring( ) [I Geotechnical S #of borings #of borings ❑Out-Of-Service Well ❑Out-Of-Service Well-Renewal ❑Cross-Connection Repair New Pump Ej Pump Replacement E]PLIMp Repair E]Raise Well Casing WELL CONSTRUC ION Drilling Method XMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other Proposed Well Depth .3Zo ft Excavation /—Z-& in diameter E]Open Bottom Gravel Pack/Gravel Size 3A. in diameter ❑Conductor Casing in diameter / Conductor Casing Depth / ft Well Casing Diameter (�, in Thickness/Gauge/ASTM Sched Q Z/ ❑Steel Plastic ❑Stainless Steel E]Other Grout Seal Depth IQJ ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix17 gal water 1:]Benton ite(20%solids) ❑Other { z Grout Placement Method Xpumped [-]Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By 'Driller Pump Contractor ❑ Other Concrete Pedestal dimensions:Width,; ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP Submersible[]Turbine []Other HP_j'_ Pump Set ft Standing Water Level D— 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. MINIMUM 24 ,OUR ADV NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)7953-7697 SIGNED TITLE JYG��'/A�y� DATE A U1 EAT M Tr F /1 t DEPARTMENT USE ONLY /� Application Accepted By I / Date I ( Z/ Area `'t- Employee ID# Grout Inspection By y/r Date q—?�Zow ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS AJC S`(y o(, CS S( PE Sc Received C k#/ Amount Date Permit/ Invoice# Well ID# Codes Info B ash Remitted Service Request# E:( S ,L 00 Z W ,0t w EHD 43-06 8/01/16 WELL/PUMP PERMIT