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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 NON-REFUNDABLE PERMIT www.sjgov.org/ehd. EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 1 yl ICI � U CITY/ZIP N m z v ,c' ' A CROSS STREET 0_) _APN_� , 1 PARCEL SIZE AND USE APPLICATION#hh G _ p OWNER NAME � � _ _ PHONEgpq-. 4 OWNER ADDRESS CITY/STATE/ZIP 1'Y JI CONTRACTOR ti � ( Y t PHONE D'1(/ /�/_`�� I��i O� 0/ CONTRACTOR ADDRESS v �C `^ 14441 - CITY/STATE/ZIP P-ky'kW bC4 V� lc- SUBCONTRACTOR/CONSULTANT �' \` •� _ PHONE SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP _ LICENSE C-67 0 C-61 ❑ D-09 ❑ Other NUMBER W4_qfif_�) EXPIRATION DATE_ BILLING PARTY: OWNER I 1 CONTRACTOR SUBCONTRACTOR/CONSULTAN I DOMESTIC WELL SAMPLING ... eneral Mineral/Coliform Bacteria(4391). ibromochloropropane(4392) Arsenic(4393) INTENDED USE Domesti /Private 0 Irrigation/Agricultural 0 Industrial 1 0 Water Quality Monitoring ❑ Soil Sampling/Characterization Public Water System__ If different from Owner: Water System Name Contact Name or Phone Number TYPE,OF WORK New 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 0 Cross-Connection Repair 0 New Pump ❑ Pump Replacement ❑ PU np Repair 0 Raise Well Casing WELL CONSTRUCTION Drilling Method Mud Rota 0 Air Zota ❑ Auger ^0 Cable Tool ❑ Push Point ❑ Other Proposed Well Depth��%-1�Q'J�Jlacavation _ I:)— in diameter ❑ Open Bottom H Gravel Pack/Gravel Size in diameter ❑ Condu for Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM ScheASgi> rl Steel X Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth 100 ft ❑ Neat Cement(94/b bag/5-10 gal water) El Sand Cement sack mix17 gal water xl Bentonite(20%solids) r.l Other Grout Placement Method Pumped 0 Free Fall 0 Other 0 Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other 0 Concrete Pedestal[]Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe [PUMP 0 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 CO NATION LAWS. MINI U 8 URA NCE NOTICE REQUIRED FOR IN PE^C�TI N�S -PLEASE CALL(209)9 -76 7 SIGNED TITLE r , �� • DATE Cl t-e DU TY L E AR TM ENT DEPARTMENT USE ONLY Application Accepted By 4 Date / Area 1 Employee ID# �✓Y`� Grout Inspection By Date PECIAL ell Permit Pump Inspection By Date I WAIVER Received Soil Boring Inspection By Date Constructed Well Depth _ ft COMMENTS <117 Gvc)&y Eallovv��a-. r - S PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Irrf Casty Remitted Service Request# D S Lin L EHD 43-06 6/11/201, I Oq (� 4 _ -�I��A/L �� (' D .I �o pnw �_ r�/5 WELL/PUMP PERMI/T�`I-t I 77•�• J[�o"1 C� �-.�`� Ij100 r) , � �;�dl�'�~� 9 1 q 9