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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 pCALL 209 953-7697 FOR INSPECTIONS EXPIRES 1✓YEAR FROM DATE ISSUED JOB ADDRESS ��,� O /!✓ J t L/ CITYZP „�� X (__ , CROSS STREET / G`/ �I"C1 AP /�— L PARCEL SIZE /O LAND USE APPLICATION# �g S OWNER NAME F/U_/� /,L.P.!`rL ' rw Air/�,G!/?C/Cl ySblV/M HONE � � �INA�cC'—e)®,ZT.I y OWNERADDRESS I�ClGi L!V CITY/STATEZP � CONTRACTOR C SCI..�3 S C-C[/�� Y////~I�_ /PHONE/ -� CONTRACTOR ADDRESS zf'T ' L�1CITY/STATEZP/�./G�P/�1�/✓,//t. L.�'7i �--`�b SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATEZP J LICENSE C-57 it C-61 l I D-09 11 Other NUMBER EXPIRATION DATE v" DOMESTIC WELL SAMPLING:I i General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)1 Arsenic(4393) INTENDED USE >(Domestic/Private G Irrigation/Agricultural I Industrial I I Water Quality Monitoring 1 Soil Sampling/Characterization I I Public Water System If different from Owner. Water System Name Contact Name or Phone Number TYPE OF WORK X New Well ❑Replacement Well a Well Alteration/Modification ❑Other 1I MonitoringWell(s) #of wells 17 SoilBoring(s) #off10nrkgs ❑Geotechnical #ofbenngs I I Out-Of-Service Well _II Out-Or-Service Well Renewal a Cross-Connection Repair i I New Pump I I Pump Replacement ❑Pump Repair ❑Raise Well Casing WELL CONSTRUCTION Drilling Method XMud Rotary IJ Air Rotary ❑Auger ❑Cable Tool a Push Point ❑ Other Proposed Well Depth^ d 0 ft Excavation_/;in diameter LJ Open Bottom ❑Gravel Pack/Gravel Size in diameter [I Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter 6 in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic 1 1 Stainless Steel i7 Other Grout Seal Depth /C ) ft ❑Neat Cement(94 Ib bag/5-10 gal water) i I Sand Cement sack mix/7 gal water X Bentonite(20%solids) i I Other Grout Placement MethodX Pumped ❑Free Fall a Other I]Retardant/Accelerator(name) PEDESTAL Installed By I Driller 1j Pump Contractor I I Other ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box 1 Stove Pipe PUMP SubmersibleSubmersible i I Turbine i I 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. t1A 4 OUR ADVANCE NOTICE REQUIRED FOR I S��TIO�ItS PLEASE CALL(209)9` 697 SIGNED / \f TITLE ' ,�// DATE 41 F Y�F�11 r 02 2018 QV/N F MFNT.ANT)' �rMFNr AR MENT US O Lx Application Accepted By, Date Qf L Area Employee ID# Grout Inspection By'Zill f ❑ PECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Amount Date Pertnitl Invoice# Well ID# Codes Ifo B Cash Remitted Service Request# -2 IQ- EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT