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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 2099)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS IS ISO �-: (�• 0AAS2 F Ci . CITY/ZIP 65CQ10'n ZQ m pry C• lL 0 -02- � D CROSS STREET �jl , CQ�(`roN�Q r) APN2-O50 7 0 -0 2- PARCEL SIZE�CLAND USE /APPLICATION# C OWNER NAME �`A5 Y PHONE 603 -�^2Q-.15 tE � �! OWNER ADDRESS .7 CITY/STATE/ZIP ES��, {o (�'45—11 �-� CONTRACTOR 1- Cnn;Y-vqs r01S J1r\ t \V'\C'k 0�� rnC . PHONE S y�l`/ 1 1 ClC1 Cr CONTRACTOR ADDRESS` -{JO L �il (Y �CY CITY/STATE/ZIP MC��, 1.R - J�✓V SUBCONTRACTOR _-_- PHONE SUBCONTRACTOR ADDRESS �CITY/STATE/ZIP LICENSE 6 -57 LI C-61 D-09 ❑ Other NUMBER 22 Y/`O R J 3 EXPIRATION DATE 57-*8 [— ZL0 DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) 1 Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial I Water Quality Monitoring ❑ 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 I 1 Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump Pump Replacement ❑ Pump Repair Ll Raise Well Casing WELL CONSTRUCTION Drilling MethodMud Rotary E! Air Rotary Auger L] Cable Tool 1j Push Point 11 Other Proposed Well Depth Q�ft Excavation Iy" in diameter ❑ Open Bottom Gravel Pack/Gravel Size_in diameter F1 Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter—& in Thickness/Gauge/ASTM Sched!5 I)P, I I Steel Plastic I_I Stainless Steel ❑ Other Grout Seal Depth \(,!:)O ft ❑ Neat Cement(94 lb bag/5-10 gal water) 11 Sand Cement sack mix/7 gal water Bentonite(20%solids) ❑ Other Grout Placement Method Pumped I I Free Fall ❑ Other I I Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller Pump Contractor I1 Other ❑ Concrete Pedestal ❑Di ensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP n Submersible❑ Turbine I-1 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 48 HOUR ADVANCE NOTICE REQUIR \R`INSPP�ECTIONS - PLEASE CALL (209) 953-7697 SIGNED b ITLE \/ T • DATE Z �O 2126 1 � Q / H � E M N E P A R T M E N T U E O N L Y Application Accepted By Date Area Employee ID# Grout Inspection By Data Ll SPEC AL Well Permit Pump Inspection By Date I WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENS f3 L �L� ZJw t N' L G LY i r PE SC Received Chec Amount Date Permit/ Invoice# Well ID# Codes Info ash Remitted Service Request# 2-U--w ooyo5 20' 0 0 EHD 43-06 8!01/16 WELL/PUMP PERMIT