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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ISea EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CIT tz,, CROSS STREET APN D -� 2D PARCEL SIZE10 _LAND USE APPLICATION# OWNER NAME I PHOt.E �O 1 AI'+�--7 04 OWNER ADDRESS O Q (1"t Ithq CrTYISTATEZ1P�i�G IO&/j G 01W;'0 � CONTRACTOR �/1 I J O T tMI�.0 N PHONE 104- ✓n lgy'V CONTRACTOR ADDRESS _ {1-1 I�I V�I`+ CITY/STATEIZIP M 0 �.StQ G& 197;K7 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS Cm/STATE2aP LICENSE C-57 0 C-61 D D-09 ❑Othef NUMBER U VI022� //.��EXPIRATION DATE 1• "/ DOMESTIC WELL SAMPUNG: General MineraVColiform Bacteria(4391)Dibromochloropropane(4392)0 Arsenic(4393) INTENDED USE mesticlPrivate D Irrigation/Agricultural D Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization D Public Water System If diff"rd from 0w Water System Nartw Canted Name or Ph—Number TYPE OF WORK ❑New Well Replacement Well ❑Well Afterstion/Modification ❑Other 0 Monitoring We(s) *of wells 0 Soil Bodng(s) 001b-k- 0 Geotechnical s Ot 60(111» 0 Out-Of-Service Well ❑Out-Of-Service Well Renewal 0 Cross-Connection Repair ❑New Pump ❑Pump Replacement 0 Pump Repair 0 Raise Well Casing WELL CONSTRUCTK)N Drilling Method Mud Rota 0 Air Rotary D Auger n Cable Tool ❑Push Point ❑ Other Proposed Well Depth ft Excavation In diameter I�r Pen Bottom Gravel Pack/Gravel Size _in diameter 0 Conducts Casing In diameter / Conductor Casing Depth ft Well Casing Diameter. In Thickness/Gauge/ASTM Sched UQ 0 Steel 0 Plastic ❑Stainless Steel ❑Other Grout Seal Depth it ❑Neat Cement(941b 689/5-10 a/wafer ....../// 9 ) D Sand Cement sack mix/7 gal water Bentonite(20%solids) 0 Other Grout Placemen ethod Pumped D Free Fall ❑Other 0 Retardant!Accelerator(name) PEDESTAL Installed By D Driller ❑Pump Contractor ❑ Other 0 COnCrete Pedestal❑Dimensions:Widthft Length ft Thick In ❑Christy Box D Stove Plpe PUMP ❑Submersibb❑Turbkte ❑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, SIGNED MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR IMPECTIONS-PLEASE CALL(209)953-7697 to TITLE ` �OwN� (� DATE Y11- 1 •yO s C 9 ?p?® q Qv) DFP�COO y ANT _ Application DEPARTMENT USE ONLY tApplication Accepted By �! Data �:� 1r�i �U/''`x Area /Te-n < Grout Inspection By / Employee IDI --� Date k ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Ins tion 8 COMMENTS x (� �— ¢onstruetad Well Depth It PE SC Received Check(/ Amount Codes Info CashRemitted Date Permit/ S Ice R Is Invoice A Well IDS -1 l I EH043-0e uotne pMp� X@QOl - WELL?UMP PERMIT