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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 / r,... CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED LA 2_"! / {'i „LIS 9 6 CITY/ZIP a Txg1 YI-' G�� JOB ADDRESS m �j [� / A D CROSS STREET • '7 �QYIv�(,`{^'I �'�APN I� /��/�� PARCEL SIZES LAND USE APPLICATION(#� p OWNER NAME 1g / f3U5N p��/L �. �2 ♦ J PHONE S 3O -- l �- 1-7 7 H OWNER ADDRESS �/gA/ ,e <NO e //t CITY/STATEIZIPj'aO (/P� ?� CONTRACTOR '44 y IZAYC PHONE 334-Y7LS_ CONTRACTOR ADDRESS CITYISTATEIZIP ,,W0v fY1{ /qy SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP '7 LICENSE 7 El C-61 El D-09 []Other NUMBER �'� IR L EXPIRATION DATE P' `_&-�V DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (439 1)❑Dibromochloropropane (4392)[]Arsenic(4393) INTENDEDUSE ykbomesticlPrivate ❑Irrigation/Agricultural []Industrial ❑Water Quality Monitoring [-]Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name an ac ame or Phone Number TYPE OF WORK &New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other ❑Monitorin Wells #ofwells #of borings If of borings Monitoring ( ) ❑Soil Borings) ❑Geotechnical F-1 Out-Of-Service Well E]Out-Of-Service Well Renewal ❑Cross-Connection Repair Z214ew Pump El Pump Replacement 0 Pump Repair ❑Raise Well Casing WELL CONSTRUCTION Drilling Method Wud Rotary E]Air Rotary ❑Auger [-]CableTool ❑Push Point ❑ Other Proposed Well Depth2.,,�2 It Excavation I�L in diameter ❑Open Bottom >LGravel Pack/Gravel Size in diameter E]Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter-,6- in Thickness/Gauge/ASTM Schad ) ❑Steel ;l0lastic ❑Stainless Steel ❑Other Grout Seal Depth-L-72 ft ❑Neat Cement(94 Ib bag/5-10 gal water) 96and Cement /c z sack m/x17 gal water ❑Bentonite(20%solids) ❑Other Grout Placement Method Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By Driller ❑Pump Contrector E] Other ❑Concrete Pedestal Dimensions:Width it Length=ftThick in ❑ChristyBox ❑Stove Pipe PUMP ®Submersible❑Turbine ❑Other HP Pump Set It 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 HQ,UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED �D �Y%1' TITLE rjf 41/Vi--J- DATE J2l 0 2�� 0 D 'QI�PARTMENT SE NLY Application Accepted Qn/I� Date Area Employee ID# I'iJ�Ub L Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By D _ Constructed Well Depth ft COMMENTS S'E-/Yf1 r- S'rWE---V— PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Co es I fo B Cash Remitted Service Request# ICA �F_QD 661 I S EHD 43-06 6/01/16 WELL/PUMP PERMIT