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WELL/PUMP PERMIT ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NUN-KEFUNDABLE NERMII JOB ADDRESS 1-U tj UJ V C, -,T ',-App CITY//Z IP 0 f wRTan -t;a CROSS STREETU I , 1'% . AyPN I I /�- —3�,rw —r 7 ,d'�ARCEL SIZE wr �� LAND USE APPLICATION # OWNER NAME /['�//�:/{�/(„7 (/ �(,Jl/�- T Crr(i[�� (L1rvl�'tl� PHONE OWNER ADDRESS /t / V I {^p�� b 6� 5u L� I OO CITY/STATE/ZIP CONTRACTOR K ( f,jrIICe1 er, /� y, C�� ('PHONE_A4��V n' CONTRACTOR ADDRESS 2-001 10r;/' f -el' �-41"- Ao �r) , .I^r k 1 C�ITYISTATE21P (�AI �, (- [ , `�[�y��-�y�"yG� SUBCONTRACTOR V t 11'ry /'� ` 191', % < PHONE 1`�-, I /- 41Cq - 9-5-16[/-+ SUBCONTRACTOR ADDRESS I kO � 414, k C- CP r�, Y r . CITY/STAAT)E21P U.� /� /� 7 ZI J LICENSE � (:-57 E C-61 i_; D-09 _ Other NUMBER V EXPIRATION DATE ( /36 (Z U 2 - DOMESTIC DOMESTIC WELL SAMPLING:. General Mineral/Coliform Bacteria (4391) - Dibromochloropropane (439") Arsenic (4393) INTENDED USE Domestic/Private a Irrigation/Agricultural Industrial 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/Modifcation -1 Other Monitoring Wells) # of wells Soil Boring(s) # of borings y%Geotechnical of borings Out -Of -Service Well Out -Of -Service Well Renewal i Cross -Connection Repair Drilling Method Mud Rotary Air Rotary 64ger Cable Tool Push Point Other Proposed Well Depth 2-5- ft Excavation 8' in diameter 1 Open Bottom a Gravel Pack/Gravel Size in diameter Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/C}auge/ASTM Sched i i Steel i i Plastic Stainless Steel i i Other Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) i i Sand Cement sack mix17 gal water _. Bentonite (20% solids) i Other Grout Placement Method _ Pumped ree 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 i Submersiblef'. Turbine I Other HP Pump Set It 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. M NCE NOTICE REQUIRED FOF/gN�S rhEC<TIONS - IPLEASE CALL (209) 953-7697 SIGNED TITLE 1 IV�`"' ` DATE V -1U 1G� �) P0 TMENT U E 91INLY Application Accepted By v ate Area4-.PE.q Employee ID# k&P, Growl Inspection B Date IAL ell Permit Pump Inspection B Date WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS EHD 43-06 revised 4114/18 (W.6 IND WELL /PUMP PERMIT