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• WELUPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED �I'{O JOB ADDRESS pD I//��PST PCSC_�4«o A VC n,4 r. CITY21P CROSS STREET N. MIwG I'Yf+h-(' Dr'.ve. APN Zl3-070 —SN/ VPARCEL SIZE Z. LAND USE APPLICATION# p OWNER NAME IJ G of d e Oa V-`; t-L�, /fI�,�JiLK�c-(+- PHONE f� / p y OWNER ADDRESS O I o f W O 'f cc cT r"w' I TATE21P W e�-4'fc-tcY d f TX / �tc�e CONTRACTOR R I I S;d e- D..I I,nn PHONE 20`t- $15 — 5q,10 CONTRACTOR ADDRESS P O Zb 1', 14S CRY/STATEIZIP Tf u•c� / G� � 96.3-79 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CRY/STATE/ZIP /p q LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER 00 2---7�P EXPIRATION DATE 0�'/3 0/ 1 DOMESTIC WELL SAMPLING:n General Mineral/Coliform Bacteria(4391)n Dibromochioropropane(4392)n Arsenic(4393) INTENDED USE ❑Domestic/Private n Irdgation/Agricultural ❑Industrial n Water Quality Monitoring n 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 n Well Alteration/Modification ❑Other ❑Monitoring Well(s) #of wells %,SoilBoring(s) �2 If of borings F1Geotechnical #of borings F1 Out-Of-Service Well ❑Out-Of-Service Well Renewal n Cross-Connection Repair ❑New Pump n Pump Replacement n Pump Repair ❑Raise Well Casing WELL CONSTRUCTION Drilling Method n Mud Rotary ❑Air Rotary )(Auger n Cable Tool n Push Point n Other Proposed Well Depth to-2S ft Excavation in diameter ❑Open Bottom n Gravel Pack/Gravel Size in diameter n Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_in Thickness/Gauge/ASTM Schad n Steel ❑Plastic n Stainless Steel n Other Grout Seal Depth to-25 It 'Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water F1 Bentonite(20%solids) n Other Grout Placement Method n Pumped Free Fall Other 'T';-:e- n Retardant/Accelerator(name) PEDESTAL Installed By n Driller n Pump Contractor ❑ Other ❑Concrete Pedestal[]Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP n 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 COFFENSATION LAWS. MINI H044R AgVAN NO CER QUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED `(�� TITLE uz f\cr DATE 1--7- 19 ��ENr EIVED 01 2019 N J UIN COUNTY E NMENTAL T EPARTMENT P-kR MENT/ SE NLY / %��,/(/,��J, Application Accepted B Date ` Area Employee ID#A�� r ' "'7 Grout Inspection ey Date TFSPECIA4 Vell Permit Pump Inspection ey Date 1 WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check## Amount Permit/ Codes Info BY. Cash temitte Date S rldce ueat III Invoice# Well ID# IZ EHD 43-08 revised 4!14!18 WELL/PUMP PERMIT