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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 CAL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Ln JOB ADDRESS 4, 64 CITY/ZIP / 1 —N/7 ` /7� ✓�" m CROSS STREET d APN 7 7/ (J�U Z PARCEL SIZE i LAND USE APPLICATION# 0 OWNER NAME + v` rn /t4 611 L T r '`, PHON �`�/ rl/�� OWNER ADDRESS ! 17A CITY/STATE/ZIP r �v "1✓ CONTRACTOR S U �vLf J PHONE �C`V/�/j CONTRACTOR ADDRESS S U� �' CITY/STATE/ZIP ' /��NV' ( LjJ2V k SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE 11C-57 ❑ C-61 El D-09 ❑ Other NUMBER O _� EXPIRATION DATE DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) 1 Arsenic(4393) INTENDED USE ,9!�domestic/Private ❑ Irrigation/Agricultural ❑ Industrial 1 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 Well ❑ 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 ❑ Push Point ❑ Other Proposed Well Depth ft Excavation 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 ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft Il Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Y4ubmersible❑ 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. MI IMy 48 HOUR/DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953- 697 SIGN Q � TITLE G'� �' I��— DATE In A � V / D N N � J D � _ liiliiiiiiiiiillliilllilillllllllllllllllllll D RTMENTj U jE ONL Application Accepted By Date / ` f Area Employee ID# Grout Inspection By p Date ` ❑ PECIAL Well Permit Pump Inspection BDate 1 �d �}_ ❑ WAIVER Received Soil Boring pection By Date Constructed Well Depth ft COMMENTS r PE SC Received hec Amount Date Permit/ Invoice# Well ID# Codes Info ash Remitte Service Re uest# Ztr'7 EHD 43-06 8/01116 WELL/PUMP PERMIT