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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELToN AVENUE-STOCKTON CA 95205-(209)488-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS (EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CrrY/ZIP VZ 2— y Jnr CROSS STREET*%� APN V J✓ lip_0 111PARCELSIZE Z-1• LANDUsEAPPLICAmoNA 8$'OWNER NAME — IPHONE /� 7OWNER ADORECITYISTATEZP 10411 ()a t1q�(-�// CONTRACTOR MA�Clll� IND (PHONE C V 22 "I CONTRACTOR ADDREU CfTY/STATIe/2]P V •+ Aq"i35-7 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDREss CITYISTATE/bP LK:ENSE 1Y67 O 1:41 O I}OH U other NUMBER.l am ExplRAnoN DATE ;/V•Liv Zl DOMESTIC WELL SAMPLING:❑General Mineral/Colitomt Bacteria(4391)❑Dibromochloropropane(4392)0 Arsenic(4393) INTENDED USE 0 DomestiMPrivate IgIfirigaticniAgriculturul 0 Industrial 0 Water Quality Monitoring ❑Soil Sampling/Characterization r.Public Water System M dM.ent Nom 0~ Waley System Nerve Con4c1 Name a Plane Number TYPE OF WORK W.Well Li Replacement Well 0 Well ARerst on/Modification 0 Other E VNT ❑Monitoring Weds) #of wells 0 SON Boring(s) 101 b-fts ❑Geotechnical s of boruge EFC n Out-Of-Service Well 0 Out-Of-Semice Well Renewal ❑Cross-Connection Repay D C New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Caal WELL CON*TRUCTION�� G Drilling Method W12d Rota 0 Air Rotary 0 Auger Cable Tool 0 Push Point ❑ Other u y ?010 Proposed Well Depth it Excavation W in diameter ❑Open Bottom 0 Gravel Pack/Gravel Size In d' ) Q C C Conductor Casing In diameter / Conductor Casing Depth R A NET ON ENT UL Ty Well Casing Diameter.11- in Thickness/Gauge/ASTM C ' eel Schad Steel b*j ❑Stainless St ❑Other E A Grout Seal Depth�_R 0 Nest Cement(94 lb Dagil-10 gat wafer) L)Send Cement x sack m fta 7 gat wsr R T MENT H'Bentonde(20%solids) ❑Other Grout Placement Method Wfumped ❑Free Fall ❑Other U Retardant/Accelerator(name) PEDf3TA Installed By D Driller ❑Pump Contractor C Other 0 Concrete Pedestal❑Dimenalons!Width_R Length R Thick in ❑Christy Boa Store Pips PUIaP :1 Submersible0 Turbine D Other HP Pump Set R Standing Water Level R 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. MI .7M � VANCE NOTICE REQUIRED F R IN PEC ONS-PL SE CALL(209)9553-71697 SIONEO 1 Tf71EIf,� J DATE-------- 41 V• 1 Y V ft TTT DEPARTMENT USE ONLY i Application Accepted By sL. �-- Date /.31'i J U Area q (� Employee ID# L n Grout Inspection By Dale ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Sod Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC RecMwd Chw W Amount Permit/ Codes Info Cash Remkted Date Service Request i Invoice# Well IDS 6 EHDube ebine WELL IPWP PERMfT