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a7 �'� ` WELL/PUMP PERMIT SAN JOAQUIN'COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT Ai. CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR ROM DATE ISSUED .iOB ADDRESS /f CITY/ZIP �j ` �/� �Z rn / fy1L�., I'1 D :ROSS STREET '. ( � APN !�(J(/�y"r {/� PARCEL SIZE LAND USE APPLICATION# o /�` ,� m OWNER NAME ' A(��,j�/�l�/,}l�+p?� J C�J�P/H2OONE (")r/Q OWNER ADDRESS /i� ' I16� I C'1"�'"r '`•'� `"r CITY/STATE/ZIP�J I & ��/ C 1 I-S, „ 1 -� -3 � CONTRACTOR /�"" \-/�� /�C /PHONEhl- CONTRACTOR ADDRESSCITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 ❑C-61 El D-09 ❑Other NUMBER-?)'; ;7 3J!''' EXPIRATION DATE —k DOMESTIC WELL SAMPLING:®General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)[-]Arsenic(4393) INTENDED USE ,Bbomestic/Private ❑Irrigation/Agricultural ❑Industrial [:]Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner Water System Name Uontact Name or Phone Number TYPE OF WORK New Well ❑Replacement Well ❑Well Alteration/Modification El Other #of borings #of borings F1 Monitoring Well(s) #of wells L]Soil Boring(s) ❑Geotechnical El Out-Of-Service Well F]Out-Of-Service Well Renewal ❑Cross-Connection Repair .New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing WELL CONSTRUCTION Drilling Method F]Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other Proposed Well Depth ft Excavation VL�-- in diameter []Open Bottom Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameterin Thickness/Gauge/ASTM Sched �_'�? ❑Steel )ejl'lastic ❑Stainless Steel ❑Other Grout Seal Depthft ❑Neat Cement(94 Ib bag/5-10 gal water) Sand Cement �L: � sack mix/7 gal water ❑Bentonite(20%solids) ❑Other Grout Placement MethoqA Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By driller ❑Pump Contractor . ❑ Other E]Concrete Pedestal dimensions:Width ft Length ft Thick in []ChristyBox ❑Stove Pipe r- PUMP Submersible[-]Turbine ❑Other HP�i 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 4 H R ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 J ! , SIGNED '-'�� %'1-'� TITLE�Ji U/'�/� DATE/,"'3 1�( i v J 4 UN p HEALTH C)Fr-� AL n c D A P T M F N T tJ c F n N i_ y Q �RTMEAfj' Application Accepted B Date Area f Employee ID# t�o Grout InspectiongB Date &"//--5 1 ❑ SPECIAL Well Permit Pump Inspection By I t t^' iDate �- �{?�ZI��'(��' ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS r tEW skrrprop 774 E Aao�P T (LIRA T E S Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# \2 k9(2,007(1 p�0 ► 3 3�� 410, 3 cs 12 2007(912 Ll EHD 43-06 8/01/16 WELL/PUMP PERMIT