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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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Ln 1.JOB ADDRESS E;ZA�) t S cl k-ML1S ly\�-�'_' CITY/ZIP CROSS STREET !/"✓/mf-98,-1 �E�� APN ?- —� —� PARCEL SIZELAND USE APPLICATION# A OWNER NAMEy.;`�F a-� �{ t-� �/� �—_.. f -�L✓`j v, PHONE Zc�i r N OWNER ADDRESS Z- � 1 � C� �M'L �� CITY/STATE/ZIP N ( —�•— Y� �'...� CONTRACTOR PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑ C-57 ❑ C-61 ❑ D-09 LI Other NUMBER EXPIRATION DATE DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural 11 Industrial 11 Water Quality Monitoring 11 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 'AOut-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary Ll Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation in diameter f I Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched a Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 lb bag15-10 gal water) ❑ Sand Cement sack mix17 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other Cl Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor Li Other ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box E Stove Pipe PUMP 1_1 Submersible❑ Turbine ❑ Other HP Pump Set ft 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. MINIMUM 24 HOUR ADVA_N5E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7 97 SIGNED TITLE C 1�J'� �•— DATE E ;DEPART Cc Al2T �.� � fiT USf_ CI LY Application Accepted By Date �7 Area Employee ID# Grout Inspection By Date U SPECIAL Well Permit Pump Inspection By [Date l LI WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Receivedheck# Amount Dae Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# POO 2 EHD 43-06 8/01/16 WELL/PUMP PERMIT