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w y 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 Q �� Ln JOB ADDRESS 2 1 CITY/ZIP \ K(�al 'l S"7(o/ m p D CROSS STREET \ e 1 APN 2-2 I I� '2.5 PARCEL SIZE 4j LAND USE APPLICATION#�J A OWNER NAME J 05 �1 r �1 PHONE 5 �o—So-1 -C�-1 iO m OWNER ADDRESS CITY/STATE/ZIPC a5ttr d V oallty - C A C CONTRACTOR O5. 111 �O• PHONE 5�H S- q-`J � CONTRACTOR ADDRESS l { �J L-4:"A CITY/STATE/ZIP W)oa�5 'v0 C f� 011 5*3 5- SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS �jCITY/STATE/ZIP LICENSE -57 LI C-61 F1 D-09 I Other NUMBER 290e1 9 - EXPIRATION DATE DOMESTIC WELL SAMPLING:XGeneral Mineral/Coliform Bacteria (4391)x Dibromochloropropane(4392) Arsenic(4393) INTENDED USE omestic/Private ❑ Irrigation/Agricultural 11 Industrial 1_I Water Quality Monitoring ❑ Soil Sampling/Characterization Public Water System If differe,'from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New%„ell Replacement Well ❑ Well Alteration/Modification U Other ❑ Monitoring We I(s) #of wells U Soil Boring(s) #of borings ❑ Geotechnical #of borings 1.1 Out-Of-Service Well LI Out-Of-Service Well Renewal [I Cross-Connection Repair ❑ New Pum ❑ Pump Replacement I I Pump Repair CI Raise Well Casing WELL CONSTRUCTION Drilling MethodMud Rotary U Air Rotary ❑ Auger U Cable Tool I I Push Point U Other Proposed Well Depth �2-snft Excavation 1�_ in diameter I I Open Bottom Y Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft R Well Casing Diameter ib in Thickness/Gauge/ASTM Sched 5o 11 Steel Wlasti, P Stainless Steel ❑ Other Grout Seal Depth �CCft ❑ Neat Cement(94 Ib bag/5-10 gal water) LI Sand Cement sack mix/7 gal water Bentonite(20%solids) ❑ Other Grout Placement Method Pumped ❑ Free Fall ❑ Other 1_I Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller Wump Contractor U Other ❑ Concrete Pedestal E_IDi ensions:Width ft Length ft Thick in Ij Christy Box ❑ Stove Pipe PUMP U Submersible F1 Turbine I I 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 ADVANCE NOTA REQU R INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED , TITLE 1 . DATE r �� L 11 O Ho u A T� DEPARTMENT USE ONLY Application Accepted By G/�- �� Date S //&ZC Area 1 i ! Employee ID# <�< Grout Inspection By Date I I SPECIAL Well Permit Pump Inspection By Date 11 WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTSw�� PE Sc Received Che Amount Date Permit/ Invoice# Well ID# Codes Info By_ Cash Remitted Service Request# L1 Md lS b Q EHD 43-06 8/01/16 WELL/PUMP PERMIT