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4 5 ` f WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 NON-REFUNDABLE PERMIT 1- y1)n.Sjg0v.org1ehd /EyX�PIRE�S I YEAR FROM DATE ISSUED Ln JOB ADDRESS r Oaf 3�S �r C� cITYIzIP vl `c, I�312 m m CROSS STREET LoySy n V APN OZqPARCEL SIZE LAND USE APPLICATION# o Cn OWNER NAME PHONE tai OWNER ADDRESS M 4�J( �,f L CITY/STATE/ZIP _94'/1 / 7 1 CONTRACTOR / 1+0U(�j� �O r { l I/ cote ST j✓lay L LIG PHONE 1 ( I l/ 63J SO2-.) CONTRACTOR ADDRESS �,� 1 N '17�Q/t S+y- 1 CITY/STATE/ZIP CY4 C (+&�I(�] G ?-k6 SUBCONTRACTOR/CONSULTANT 1 P-I h /0Q4 ` p J PHONE/ -I ( �0 - )3q 5 / SUBCONTRACTORICONSULTANT ADDRESS (DO) c/4 AI e- r R -CI(T�Y/STA E/ZIP__S C'k (_g ZOb LICENSE `p C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER_ D 9 9 LIS I _ EXPIRATION DATE BILLING PARTY: ❑OWNER ❑CONTRACTOR A/SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑ Arsenic(4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring /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 ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings Geotechnical #of borings 0 Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump ❑ Pump Replacement ❑ Pump Repair 0 Raise Well Casing WELL CONSTRUCTION ^� Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool /Push Point ❑ Other f`� Proposed Well Depthq' 0 ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size - 1 ter ❑ Conductor Casing in diameter / Conductor Casing Depth ft v/�/ Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Ste�L,- ❑ Ottier� Grout Seal Depth ft +p(Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement �0�O sack m / I water ❑ Bentonite(20%solids) 0 Other /iQ v/H Grout Placement Method Pumped D Free Fall ❑ Other ❑ Retardant/Accelerator(name) FA NT n' PEDESTAL Installed By 0 Driller ❑ Pump Contractor ❑ Other T ❑ Concrete Pedestal DDimensions:Width ft Length ft Thick in ❑ Christy Box 0 Stove Pipe PUMP 0 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 48 U VANCE NOTICE REQUIRED FOR(`IINSCPGEC�TTIONS - PLEASE CALL(209) 953-7697 SIGNED TITLE )7�r ` I�VI°�/�I�CJ DATE61R ZO/� ———————————————— — _++ ------------------- TT DEPARTMENT USE 0 LY Yat✓c� Application Accepted By Date ( Area 3lqq Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Permit/ Codes Info By Cash Remitted Date Service Re uest# Invoice# Well ID# EHD 43-06 6(11/2019 Q 0[--/ �� WELL/PUMP PERMIT