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Apo 2g131016 /Z�-310 -ZS ' -PN Zti 13 00 34u--1-61 WELL/PUMP PERMIT PN 77 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 Epf HAZELTON AVENUE-STOCKTON CA 95205-(209)466-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR IN54ECTIONS EXPIRES 1 YEAR FROM DATE ISSUED (� �t .1915337- T JOB ADDRESS 2,450 W95 Sc oe CITY/ZIP a. Q 5 3 m CROSS STREE n ♦V a APN PARCEL SIZE LAND USE /AP1PLICATION## / (J o OWNER NAME f V Ke F<��l.y u PHON 61 9 t�Q I-+4-5if N OWNER ADDRESS 5odry5. ./Tex4-5 ✓ / � �� 1 O 0 CITY/STATEIZIP ? /`{QV O CONTRACTOR T-,yWI Dr t fl'I'4r 1_L�y� C -A I I,PHONE 16,)3 '- v�. C} CONTRACTOR ADDRESS 53� Ua IVtAVr) S+.Ma+ CITYISTATE/ZIPW'_ �YQ►ir[a,rlf'a/CAI ^� SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CIN/STATE/ZIP LICENSE `OC-57 �=C-61 D-09 -Other NUMBERIQ EXPIRATION DATE O 2-12-1126zo DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)F Dibromochloropropane(4392)Ll Arsenic(4393) INTENDED USE ::Domestic/Private -Irrigation/Agricultural �]Industrial D 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 U Well Alteration/Modification Other _Monitoring Well(s) #of wells Soil Bohng(s) /� n of honnp Geotechnical 9 of borlogs Out-Of-Service Well r-Out-Of-Service Well Renewal L Cross-Connection Repair New Pum ❑Pump Replacement r Pump Repair Raise Well Casing WELL CONSTRUCTION / Drilling Method C Mud Rotary F Air Rotary /Auger F Cable Tool Push Point ❑ Other Proposed Well Depth/0-Z 0 ft Excavation in diameter D Open Bottom U Gravel Pack/Gravel Size in diameter 0 Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thicknesss/Gauge/ASTM Sched ❑Steel ❑Plastic U Stainless Steel U Other Grout Seal Depth/p -ZO ft l Neat Cement(94 Ib bag/5-10 gal water) U Sand Cement sack mixn gal water U Bentonite(20%solids) Other y Grout Placement Method ❑Pumped Free Fall 104 01her7QENl1 IC D Retardant/Accelerator(name) PEDESTAL Installed By U Driller Pump Contractor i Other Concrete Pedestal CDimensions:Width fl Length ft Thick in D Christy Box ❑Stove Pipe PUMP -:SubmersibleO Turbine Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT 1 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. MUM 4 NOU AD A N TICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)95�3-76697 SIGNED TITLE �I l i DATE �+O � N �9 (Tti�p�RH c)41,V� MFNT AR M E N T U E (INNLLLY �� Application Accepted By te!�?� C'� Area`l� ,p� Employee ID# " - Grout Inspection By Dale C SPECIAL Well Permit Pump Inspection By Date /�J,_/{_-�� i_ WAIVER Received � Soil Boring Inspection By `\ Date ' r / _ Constructed Well Depth It COMMENTS h A PE SC Received Check#/ Amount Permit] odes Info Cash a fitted Date Se 'ceRe uest# Invoice# Well ID# 7 EHD 43-06 M1/16 Wi(E 5130 WELL/PUMP PERMIT