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WELL/PUMP PERMIT /v,4195 o SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLEP€ER�M/IT CALL(209)953-7697 FOR INSPECTIONS CEXPIRES 1' YEAR FROM DATE ISSUED JOB ADDRESS / yi CITY/ZIP qJLU mU CROSS STREET MCI ) / APN U I —017 `� PARCEL SIZE C LAND USE APPLICATION# m OWNER NAME PAOT lie PHONE OWNER ADDRESS � CITY/STATE/ZIP GS / 1 PHONE/i - IY( SCn �4LLklLz jerr� l > 'Z�C1 CONTRACTOR ADDRESS 6 z . 'Idu&JAlf W CITY/STATE/ZIP L-ad C-4- qt-) SUBCONTRACTOR ✓ PHONE Ar,4 SUBCONTRACTOR ADDRESS /v CITY/STATE/ZIP LY4 [I11111 LICENSE f(C-57 C-61 D-09 Other NUMBER Cl U 9 Q4 1� EXPIRATION DATE 5/'31/ 1 DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE I I Domestic/Private ❑ Irrigation/Agricultural I I Industrial I I Water Quality Monitoring I_I Soil Sampling/Characterization I Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK I I New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other I I Monitoring Well(s) #of wells I I Soil Boring(s) #of borings (tl Geotechnical "3 #of borings I I Out-Of-Service Well I I Out-Of-Service Well Renewal 1 Cross-Connection Repair I I New Pum ❑ Pump Replacement I I Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method .D(Mud Rotary ❑ Air Rotary ?(Auger L1 Cable Tool LI Push Point I I Other Proposed Well Depthft Excavation in diameter ❑ Open Bottom 11 Gravel Pack/Gravel Size in dla I I Conductor Casing in diameter / Conductor Casing Depth ft l7 08 2019 Well Casing Diameter in Thickness/Gauge/ASTM Sched F] Steel F1 Plastic I I Stainless Steel ElQ J Voq- Grout Seal Depth ft )(Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement ")ANME I Bentonite(20%solids) ❑ Other F—ALTy NT Grout Placement Method I I Pumped ❑ Free Fall the ❑ Retardant/Accelerator(name) MENT PEDESTAL Installed By 1-1 Driller F_I Pump Contractor CI Other CI Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP I I Submersible)I Turbine I I 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. MINIM M 48HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 953-7697 SIGNED ' TITLE �I^` S f�Ff EnG:',7e DATE LI/0/ E ARTMENT U E NLY Application Accepted By Date / Area Employee ID# AWW Grout Inspection By Date I I PECIAL Well Permit Pump Inspection By 4 Date I I WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received he Amount Date Permit] Invoice# Well ID# Codes Info B as Remitted Service Request# EHD 43-06 8/0: 16 WELL/PUMP PERMIT