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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 I1%JN-RCrUNUAt3Lt 1-�t:KMI I LALL LUa U0.5- IOU/ FOR INSPECTIONS IMAPIKLb 1 YEAR FROM DATE ISSUED JOB ADDRESS W CITY/ZIP CROSS STREET [602-4 PIX APN f.V q 0'0 1 PARCEL SIZE". LAND USE APPLICATION # DOMESTIC WELL SAMPLING: D General Mineral/Coliform Bacteria (4391) D Dibromochloropropane (4392) D Arsenic (4393) NTENDED USE ❑ Domestic/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 D New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other D Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings d Geotechnical # of borings ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair Naw Grilling Method 46 Mud Rota ❑ Air Rotary ,t Auger ❑ Cable Tool ❑ Push Point D Other proposed Well Depth' o ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel D Other Grout Seal DepthtE — 3 ft 4 Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mixn gal water ❑ Bentonite (20% solids) ❑ Other 3routPlacement Method .dPumped ❑ Free Fall ❑ Other ❑ Retardant I Accelerator (name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal DDimenslons: Width it Length it Thick in ❑ Christy Box D Stove Pipe PUMP ❑ Submersible❑ Turbine D 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. MINIMUM 48 H R A VANCE NOTICE REQUIRED FOR �,/INSPECTIONS - PLEASE CALL (209) 9 3-7 97 SIGNED {� s � TITLE .J 1 ff !i • [ 9 % %I.er DATE P4_MENTI UAll S Application Accepted By Date Grout Inspection By Date Pump Inspection By 4 Date Soil Boring Inspection By / "h40UH 4441:4—f Date 9 I1 COMMENTS N 0 X w IEN IVE® 16 2018 JIN COUNTY NMENTAL EPARTMENT Area Employee ID4 A& r ❑ SPECIA ell Permit ❑ WAIVE Received Constructed Well Depth ft EHD 43-06 revised 4/14/18 WELL /PUMP PERMIT OWNER NAME" PHONE OWNER ADDRESS MI(/V ( iL/ r/� . CITY/STATEIZIP N �` CONTRACTOR Klein jein kVer CONTRACTOR ADDRESS Z001 AyA _AI dVl CP�HOON./E _e f `yS"_/00Z J `/ SUBCONTRACTOR Y )I L/ o rj uj Y) (A PHONE fJ SUBCONTRACTOR ADDRESS I `3 Z. ( c�c c h �r`S f Dr CITYY/STATE21P 6 / il` A A LICENSE QfC-57 D C-61 D D-09 ❑ Other NUMBER "0 04 EXPIRATION DATE LtL % �1 DOMESTIC WELL SAMPLING: D General Mineral/Coliform Bacteria (4391) D Dibromochloropropane (4392) D Arsenic (4393) NTENDED USE ❑ Domestic/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 D New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other D Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings d Geotechnical # of borings ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair Naw Grilling Method 46 Mud Rota ❑ Air Rotary ,t Auger ❑ Cable Tool ❑ Push Point D Other proposed Well Depth' o ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel D Other Grout Seal DepthtE — 3 ft 4 Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mixn gal water ❑ Bentonite (20% solids) ❑ Other 3routPlacement Method .dPumped ❑ Free Fall ❑ Other ❑ Retardant I Accelerator (name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal DDimenslons: Width it Length it Thick in ❑ Christy Box D Stove Pipe PUMP ❑ Submersible❑ Turbine D 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. MINIMUM 48 H R A VANCE NOTICE REQUIRED FOR �,/INSPECTIONS - PLEASE CALL (209) 9 3-7 97 SIGNED {� s � TITLE .J 1 ff !i • [ 9 % %I.er DATE P4_MENTI UAll S Application Accepted By Date Grout Inspection By Date Pump Inspection By 4 Date Soil Boring Inspection By / "h40UH 4441:4—f Date 9 I1 COMMENTS N 0 X w IEN IVE® 16 2018 JIN COUNTY NMENTAL EPARTMENT Area Employee ID4 A& r ❑ SPECIA ell Permit ❑ WAIVE Received Constructed Well Depth ft EHD 43-06 revised 4/14/18 WELL /PUMP PERMIT