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Z 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 li CITY/ZIP LI �J y m CROSS STREET La APN U PARCEL SIZE0,3-/ LAND USE APPLICATION# m OWNER NAME C PHONE OWNER ADDRESS (9 72 / kya I"W J / / CITY/STATE/ZIP�� CONTRACTOR G lJve4ens PHONE 2L)t? CONTRACTOR ADDRESS CITY/ TATE/ZIPS ( � S �JJ SUBCONTRACTOR 4 PHONE SUBCONTRACT ADDRESS C TY/STATE/ZIP LICENSE C 57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE --3 DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial I Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service LVell ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool I I Push Point ❑ Other Proposed Well Depth ft Excavation in diameter f_l Open Bottom ❑ Gravel Pack/Gravel Size in diameter C] Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Sched I I Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal wate/) ❑ Sand Cement sack mix17 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other 11 Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller C] Pump Contractor ❑ Other 11 Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box I I 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 MPENSATION LAWS. NI KM 2 HO DV N NO ICE REQUIRED FO PE NS - PLEASE CALL (209) 950-76 f9 SIGNED / TITLE ' DATE 6 9, V P E N 6 DEPARTMENT USE ONLY n / Application Accepted Qy i� '�' Date �' �� -L- Area Employee ID# A X1111 !! Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date o C] WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE Sc 4Receive]d Check#/ Amount Date Permitl Invoice# Well ID# Codes Info Cash Remitted Service Re uest# OS 15 16 7 EHD 43-06 8/01/16 WELL/PUMP PERMIT