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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 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 92-10-3 -tS a no Or'. CITY/ZIP S+ex-k4lo k �1 I Z, m / D CROSS STREET APN 0%-1 06- 23 PARCEL SIZEvUSE[APP_PLICATION#(� 7�} A *� �J ZTILiy m 1 V CLAY' e Q PHONE OWNER NAME q'►1C- Lf-o-, C � OWNER ADDRESS �/� 1 (7 CITY/STATE/ZIP - -1 J 2— CONTRACTOR �r�\AS P S r\"\V1�n �hC' A APHONE c�t� -1!12-0 C,< CONTRACTOR ADDRESS 1"1 A (b e cS V-A CITY/STATE/ZIP /�/1 O d,-5 / G c^ �/� SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS //C--IITY/STATE/ZIP /y LICENSE )<C-57 ❑C-61 El D-09 ❑Other NUMBER 10� Z EXPIRATION DATE v DOMESTIC WELL SAMPLING:49eneral Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE Domestic/ rivate ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner: a er ys em ame Contact Name or Phone Number TYPE OF WORK ' New Well F1 Replacement Well ❑Well Alteration/Modification El Other ❑Monitoring Well(s) #of wells ❑ #of borings Soil E]Geotechnical #of borings F]Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair ❑New Pum []Pump Replacement ❑Pump Repair ❑Raise Well Casin WELL CONSTRUCTION Drilling Method ud Rotary E]Air Rotary [-]Auger ❑Cable Tool El Push Point ❑ Other Proposed Well Depth 240 ft Excavation (Z r/ 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 Sched 00 ❑Steel Xlastic ❑Stainless Steel ❑Other Grout Seal Depth `G 0 ft ❑Neat Cement(94/b bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water ',Bentonite(20%solids) ❑Other Grout Placement Method umped ❑Free Fall ❑Other []Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller E]Pump Contractor ❑ Other E]Concrete Pedestal dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑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) 953-7697 SIGNED - TITLE ✓t'-t lIf T e DATE >t 1 � 141 V' 1" 1 Y it wl�cl 7P 1 a A E Vi l C D N EIV EP RTIAtNT ' sl= ONLY Application Accepted Date Area Empiuvee!DW Grout Inspection By lWCu[% }pate 9/3 ZCI ❑ PECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed el Depth ft COMMENTS /J V6�On�G' 111-411� — Al /`)7721�1 L v C/ cJ on! i a z Zvi To J /6 � A110 PE Sc Received Qchecw Amount Permit/ Invoice# Well ID# Info B ash Remitted D to Service Request# 3 Wf(VS vNivueD 2 l EHD 43-06 8/01/16 N� / �/ /�v L. 7 LlL o .y WELL/PUMP PERMIT