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WELL/PUMP PERMIT ,SAN JGaQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE [/Pl,E/RM(IT � r CAL(L� 209 953-7697 FOR INSPECTIONS EXP!RES 1 YEAR FROM DATE ISSUED JOR ADDRESS — z CITY/ZIP f0D% m CROSS STREET �>' ' �1 APN��JI I�/ �/ PARCEL SIZE _LAND USE APPLICATION# A OWNER NAME o /— 111-W 12- V Y- l�"�/.m /7 PHONE rn. OWNER ADDRESSV44tZtr� , (/tom C dG 5� CITY/STATE/ZIP CONTRACTOR /y` SS /4�4t, l PHONE -2, CONTRACTOR ADDRESSy 7� CITY/STATE/ZIP G' SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE SRC-57 El C-61 El D-09 ❑Other NUMBER '20731i 1i EXPIRATION DATE DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) INTENDED USE >40mestic/Private ❑Irrigation/Agricultural []Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name L;ontact 17 r Phone Number TYPE OF WORK OVNew Well ❑Replacement Well ❑Well Alteration/Modification E]Other #of borings #of borings ❑Monitoring Well(s) #of wells ❑Soil Boring(s) []Geotechnical ❑Out-Of-Service Well E]Out-Of-Service Well Renewal ❑Cross-Connection Repair ew Pump ❑Pump Replacement ❑Pump Repair ❑Rais)e'Well Casing WELL CONSTRUCTION Drilling Method,4jaf/Iud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point/❑ Other Proposed Well Depth 3 00 ft Excavation in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter [:]Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter 6- in Thickness/Gauge/ASTM Schede Steel lastic El ss,Steel ❑Other Grout Seal Depth? ft E]Neat Cement(94 Ib bag/5-10 gal Iter) and Cement ��: ��sack mix17 gal water ❑Bentonite(20%solids) ❑Other Grout Placement Method ❑Pumped ❑Free Fall ❑Other % ❑Retardant/Accelerator(name) PEDESTAL Installed By Driller El Pump Contractor Other .^ E]Concrete Pedestal dimensions:Width �/ Length ft Thick 7zf in ❑Christy Box ❑Stove Pipe PUMP ; Submersible[-]Turbine ❑Other HP Pump Set ft Standing Water Level ft 1 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. MINI M 4 MOADVANCENOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)) 953-76997 SIGNED / / TITLE ��L[/�+�f^ DATE G ��y /6 i iL I i 1 SAN, OA 10 fill 3TI i d v i" F1fC i MEN r USE ONLY Application Accepted EF?-A�C%V- Date ✓ Area Employee ID#19WfO Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Construct e II Depth ft COMMENTS PE SC Received C Amount Date Permit/ Invoice# Well ID# Codes Info By, Cash Remitted Service Request# 3 ` 12-lghto IZ009 ,VDo D. 14106 Do 35 kd I l 12 sd 00 3! Z- EHD 43-06 8/01/16 WELL/PUMP PERMIT