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f WELL/PUMP PERMIT q SAN JOA�QUIN COUN 1Y ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 2V5i1 S ansIc I611t `y CITY/ZIP`/��f�� s Jmm L CROSS STREET W.P J+ 1�1T^�(+-A (1 APN Z 0' 1 ♦� 3 1 it PARCEL SIZE r• 3 LAND USE APPLICATION# �y OWNER NAME g�-@= ��C h h T�ti L. RHONEcn Z7 O �!�L y OWNER ADDRESS \� �-�' j T" CITY/STATE/ZIP Cg A i33/6k7 CONTRACTOR 9�C+h��,`'/"1)y\S �' e �M �� PHONE .5 CONTRACTOR ADDRESS (+` 164? r5 24 CITY/STATE/ZIP 6(4 � NO SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE �y - DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) 1 Arsenic(4393) INTENDED USE )W(Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 11 Soil Samplinc�fGl �cterization L1 Public Water System 10 If different from Owner: Water System Name Contact Name or Pho TYPE OF WORK yNew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical uiv amngs ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection R4It J 11New Pump ❑ Pump Replacement 11 Pump Repair ❑ Raise Well Casing ENV AQUfN COUN WELL CONSTRUCTION NrALTH DeL ARTIIMENT Drilling Method XMud Rotary ❑ Air Rotary ❑ Auger ❑ C9ble Tool ❑ Push Point 11 Other Proposed Well Depth 300 ft Excavation I I 1 in diameter ❑ Open Bottom Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter Iin ThkneqGauge/ASTM Sched ❑ Steel Plastic ❑ Stainless Steel 11 Other Grout Seal Depth ' ft ��[1 Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water Bentonite(20%solids) ❑ Other Grout Placement Method • Pumped LiFree Fall F1Other [-1 Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller 1-1 Pump Contractor ❑ Other 11 Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box 0 Stove Pipe PUMP Ll 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 COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 9533--769y7 /Dt r IIT e- DATE SIGNED �. ,��- TITLE { � 4 y ry 7EPARTMENT USE O }N(LY 1 /� Application Accepted By Date 13 - / J Area /o�! Employee ID# Grout Inspection By a0i Nsc, Date C� d0/zlk ❑ SPECIAL Well Permit Pump Inspection By Date LI WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS jj� X 11 11 . 3 r PE SC Received Ch Amount Date Permit/ Invoice# Well ID# Codes Info By,, Cash Remitted Service Re est# 1136 4 Iry S 3 'i � g �3 w EHD 43-06 8101/16 WELL/PUMP PERMIT