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�1 t IWELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NUN-KEFUNDABLL}E VERM(IT� UALL (LUV) VOS-fbUf FOR INSPECTIONS tAF'IKtb 1 YEAR FROM UATE ISSUED JOB ADDRESS U{ �'�J�.�� 0• \ IR17 CITY/ZIP [�\�►7(i `'��,� �> CROSS STREET \� n G1 Y� �- �` C 1] . APN 00 � r�6 V � J PARCEL SIZE 5 c1C LAND USE APPLICATION #' OWNER NAME G/-erCN(-A N t I�G\r 1 PHONE VI ��© �/� / J —J0 OWNER ADDRESS, l j00 1��/ i COVI R �, CITY/STATE/ZIP /� �C�t�\ pp/r f—\ �1 vly� Do CONTRACTOR `� �/ Ci1 1� �J Dc-\\\,r)3 IJ t \ \` \ r) q (]� 3G 9 — 27 /q CONTRACTOR ADDRESS o• O �( 4 Q CITY/STATE/ZIP / -PH`O`NE &n 1 T CA G 5 C 3 "a SUBCONTRACTOR SUBCONTRACTOR ADDRESS LICENSE LAC -57 KC -61 ❑ D-09 ❑ Other PHONE CITY/STATE/ZIP --] NUMBER O� C�� tl EXPIRATION DATE DOMESTIC WELL SAMPLING: &1eneral Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) INTENDED USE ']KDomestic/Private ❑Irrigation/Agricultural ❑Industrial El Water Quality Monitoring El Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK )SNew Well ❑ Replacement Well ❑ Well Alteration/Modification E] Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑Geotechnical E] Out -Of -Service Well El Out -Of -Service Well Renewal ❑Cross -Connection Repair # of borings ,New Pum ❑ Pump Replacement ❑ Pum Re air ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method lrq Mud Rotary F] Air Rotary ❑Auger ❑Cable Tool E] Push Point ❑ Other Proposed Well Depth0-75 _ft Excavation in diameter E] Open Bottom KGravel Pack/Gravel Size 1/4 — in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter C) in Thickness/Gauge/ASTM Sched CI Rc ❑Steel .Plastic [_]Stainless Steel ❑Other Grout Seal Depth )i, OC) ft ❑ Neat Cement (94 Ib bag/5-10 gal water) �R Sand Cement In -3 sack mix/7 gal water ❑ Bentonite (20% solids) ❑ Other Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By N Driller ❑ Pump Contractor ❑ Other Concrete Pedestal dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP Submersible❑Turbine [-]Other HP Pump Set C j 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 i;N.: ^^""ut2i2cIVT riiVU Hl I iVc 'vi+i T f•I I irlC ::iaLiFVriiviA CONTRACTORS STATE LICENSE BOARDANDTI I:,T 1 A■� ...,�...^LIY N:C E WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS,1- PLEASE CALL (209) 953-7697 SIGNED TITLE \' , ,, r P!y'C • } DATE G' 93.1 \'7 r -D PARTMENT USE ONLY Application Accepted By Date 9 2 `i Area �� ' Employee ID# Grout Inspection By Date i v f / F;- ❑ SPECIAL Well Permit r Pump Inspection By Date 2 ❑ WAIVER Received Soil Boring Inspection By Date COMMENTS '� X; 5) i n i' 1,1% 2 I/ f I M A- r Constructed Well Depth ft PE Codes SC Received Info 13y c ash Amount Remitted Date Permit/ Invoice # Well ID# Service Request # y3G4 '03'73(e7 3`�► b ys11UC►373 , EHD 43-06 8/01/16 WELL /PUMP PERMIT