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WELL/PUMP PERMIT i [� SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - 9 4 - 0 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Aa N JOB ADDRESS vezralCITY/ZIP m D CROSS STREET APN V/, O PARCEL SIZE- LAND USE APPLICATION# o NE OWNER NAME nr 'Tr / PHO ( T`J( ham/ OWNER ADDRESS ^ • TY/STATE/ZIP V— CONTRACTOR -+-{/ PHONE�� CONTRACTOR ADDRESS Iew CITY/STATE/ZIP SUBCONTRACTOR / PHONE SUBCONTRA7-57 ADDRESS C /STATE/ZIP LICENSE 11 C-61 I I D-09 I1 Other NUMBER fl EXPIRATION DATE _MIX DOMESTIC WELL SAMPLING: II General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)a Arsenic(4393) le INTENDED USE omestic/Private I I Irrigation/Agricultural I I Industrial (I Water Quality Monitoring ❑ Soil Sampling/Characterization '001❑ 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 1 Other I I Monitoring Well(s) #of wells I Soil Boring(s) #of borings ❑ Geotechnical #of borings 11 Out-Of-Service II F1Out-Of-Service Well Renewal F] Cross-Connection Repair 11 New Pum Pum Re lacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method I1 Mud Rotary I1 Air Rotary I I Auger I I Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter i i Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched _l Steel F1Plastic ❑ Stainless Steel I I Other Grout Seal Depth ft ❑I Neat Cement(94/b bag/5-10 gal water) I i Sand Cement sack mix17 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method I Pumped I I Free Fall CI Other I I Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller _I Pump Contractor ❑ Other 11 Concrete Pedestal I IDimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersible❑ Turbine 1_I Other HP Pump Set ft Standing Water Level ft I HEREBY CE TIFY 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 WORKER OMPENSATION LAWS. I H AD E N T E REQUIRED FOR I SPECTIO PLEASE CALL(209) 90-76 / SIGNED TITLE DATE 0 IIAlip J 011 M 774T -1 4� I PTMENT USE ONLY C el Application Accepted By Date Area Employee ID Grout Inspection By ��// Date LJ SPECIAL Well Permit Pump Inspection By bf t�1alG Sa6tem Date 'tom Ll WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC ReceivedqhpddV Amount Permit/ od Info B ash emitted Date Service Re uest# Invoice# Well ID# S•2°I.1 1J(' EHD 43-06 8/01/16 WELL/PUMP PERMIT