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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 209 3-7697 FOR INSPECTIONS Q EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS O 0 CITY/ZIP P-[/D1 �S m CROSS STREET NN L'X r L1 APN /i�("7 D 0� PARCEL SIZE I T.P 1LAND USE APPLICATION##� y��w A MOO O n `T� PHONE UQ-- 1� V ► m OWNER NAME �/ V �/ �V �/ V �1 1 y OWNER ADDRESS /y l' 0 CITY/STATE/ZIP,A.,(,�r n 6 366 CONTRACTOR N o s A is D- r i l l!y-,i -�-� N PHONE r�I C:2-4q CONTRACTOR ADDRESS l� 11' 1 r5 CITY/STATE/ZIP M"Je5 rnL .15,35'1 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS tC-I`TYISST��ATE/ZIP LICENSE -57 El C-61 ❑D-09 El Other NUMBER l�l�U(p�� EXPIRATION DATE ^' �f DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) INTENDED USE ❑Domestic/Private Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name Gontact Name or Phone Number TYPE OF WORK XNew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other El Monitoring Well(s) #of wells ❑Soil Boring #of borings s) E]Geotechnical #of borings [-I Out-Of-Service Well E]Out-Of-Service Well Renewal ❑Cross-Connection Repair ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing WELL CONSTRUCTION Drilling MethodX Mud Rotary El Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other Proposed Well Depth ft Excavation t in diameter E]Open Bottom Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched 2-oo ❑Steel '�Wlastic El Stainless Steel ❑Other Grout Seal Depthft ❑Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water Bentonite(20%solids) ❑Other Grout Placement Methodumped ❑Free Fall El Other ❑Retardant/Accelerator(name) PEDESTAL InstalledBy ❑Driller -3mpump Contractor ❑ Other Concrete Pedestal dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ElSubme,sibleElTurbine ❑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. MIN 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED G�� -- --" -' TITLE y-"1 �C�� DATE l G - c-b C Z> F-1 Fr �b -ic crn eF a 11 D E P AT M E N/T S E ONLY r l Application Accepted By ate Co Area Employee ID# ' Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth_2c->q ft COMMENTS 4 S_ Q V-,-A_ -.J' PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info By Cash Remitted Service Request# EHD 43-06 8/01/16 WELL/PUMP PERMIT