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z 4 WELL/PUMP PERMIT ;�;'IdlL �� AN A INC COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - 69 4 �� S JO QU OU O (3 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS soon D {L�� r n AIL CITY/ZIP- �, 6,4 m CROSS STREET t -*-V N ��C.LY\ P o z`� �D D C,V S 1 �+ APN PARCEL SIZE r LAND USE APPLICATION#Q / 7 (1 X OWNER NAME 1�/�/f�T a\ 1_ J�C�\ - I PHON •'—r JL Z P In OWNER ADDRESS i go / ; (\-',Cn ��v�� c4. CITY/STATE/ZIP �`C�e�C'�I, CP (15-30e7 CONTRACTOR �CIS�`�n�� C7t/1�1AA11 t_� --7-In Ll 1PHON�� Y 1`V('�o� CONTRACTOR ADDRESS k 9"I�� i'-1 L -Lt<1 1 ��- CITY/STATE/ZIP ,I,W\CL(- C13 '-1� �L( SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE L1 C-57 11C-61 Ll D-09 I-Other OZ I NUMBER -Q04�(a EXPIRATION DATE DOMESTIC WELL SAMPLING: i I General Mineral/Coliform Bacteria (4391) i Dibromochloropropane(4392) i 1 Arsenic(4393) INTENDED USE Omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number 11 TYPE OF WORKw Well Ll Replacement Well 11 Well Alteration/Modification El Other Well Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ O t-Of-Service Well F1Out-Of-Service Well Renewal ❑ Cross-Connection Repair Zew 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 ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) 0 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 Submersible[] Turbine ❑ Other HP Pump Set ft Standing Water Level Iti Z 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. MIN UM 48 HOUR ADVANC TIC QUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 q SIGNED TITLE �h�f�C�C7 DATE n 0 A Vh lR/C uNFT I DEPARTMENT US',E ONLY Application Accepted By 'I pw Ix to%-S Date { �� Z� Area Employee ID#�e4'h Grout Inspection By Date i pp ❑ SPECIAL Well Permit Pump Inspection By� ',^ %1 Date \ 1 �Q�� ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Amount Date Permit/ Invoice# Well ID# Codes Info B ash Remittgo Service Re ue t# A77—D WP0013112110 EHD 43-06 8/01/16 WELL/PUMP PERMIT