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WELL/PUMP PERMIT Pte ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT L CALL 2,t0�9y 953-7697 FOR INSPECTIONS /EXPIIRE4 1�YEARR FROM DATE ISSUED v { L CITY/ZIP Zi"Jfl �� q S m JOB ADDRESS GI m CROSS STREET A N O PARCEL SIZE / / / ND US-EtAPPLICATION# OWNER NAME �) CJS4Z �` �`��liman 611, �" L'J PPfl �II HONE C� 10' rCn � OWNER ADDRESS J�"fes / /`LJ &Oy�/X 7Q,� CITY/STATE/ZIP Gj r7) CONTRACTOR Gr►2�� L1I J/P/HO/N'E/ya/S �f�� CONTRACTOR ADDRESS �G� �r CITY/STATE/ZIP Cy LY✓ �`y �°f0' SUBCONTRACTOR PHONEL^'/' +� /2-0 SUBCONTRACTOR ADDRESS .�CITY/STATE/ZIP LICENSE jjj�-57 [j C-61 ❑D-09 ❑Other NUMBER`S //�w EXPIRATION DATE DOMESTIC WELL SAMPLING:XGeneral Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)[]Arsenic(4393) INTENDED USE Domestic/Private ❑Irrigation/Agricultural [-]Industrial E]Water Quality Monitoring El Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name (-;ontact Name or Phone Num er TYPE OF WORK ` Jew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other { #of borings #of borings El Monitoring Well(s) #of wells E]Soil Boring(s) ❑Geotechnical e%,- ❑OUt-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair 4. tcC 1 , 2017 I%ANew Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing Sq WELL CONSTRUCTION EA►ViRON OUN7j. Drilling MethoddINud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other HEALTH DE ARQ Proposed Well Depth2-W ft Excavation G in diameter [_]Open Bottom Gravel Pack/Gravel Size in diameter ❑Conduct Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched -2-DO ❑Steel ;Plastic El Stainless Steel ❑Other Grout Seal Depth ft [_-]Neat Cement(94 Ib bag/5-10 gal water) 'Sand Cement ,l'J, ;2—sack mix/7 gal water ❑Benton ite(20%solids) ❑Other Grout Placement Methods ePumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By Driller ❑Pump Contractor ❑ Other E]Concrete Pedestal dimensions:Width ft Length ft Thiclrr in ❑Christy Box ❑Stove Pipe PUMP .Submersible❑Turbine [-]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 2 HOUADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-769/7 SIGNED TITLE `Jl-iJ� Z=r DATE F" t 7 d 41 Y - r v A ` PARTMENT USE ONLY Application Accepted By Date 'I I / Area I �� C' Employee ID# Grout Inspection By Date 1Z / ,`1 ❑ SPECIAL Well Permit / Pump Inspection By _ Date c , '1, ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth 3z6 ft COMMENTS pp r- oEl�b 9 19 PE Sc Received C Amount Date Permit/ Invoice# Well ID# Codes Info ash Remitted_d Service Request# j U / .P-b � - C3 ti 14 EHD 43-06 8/01/18 �� V / " �}' WELL/PUMP PERMIT