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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 NON-REFUNDABLE PERMIT WWW.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 1 � 'ibcAti CITYIZIP II 11 t m G�ID n CROSS STREET�w� _O( APN / — z-60 _PARCEL SIZE LAND USE APPLICATION# m m OWNER NAME t S(' CJio PHONE ' e�I N OWNER ADDRESS m-4- yrs .,/ jI CITY/STATE/ZIPc66& M HJTr i p CONTRACTOR (,o,*S-r Ex PoAkTro/J/ Z'iv C PHONE 10 CONTRACTOR ADDRESS �� 30 X-L33 , CITY/STATE/ZIP JGSC�LQN �'T S3� SUBCONTRACTORICONSULTANT o L0e,/A ENEK4i/ �G_ _ PHONE14a�130 -A SUBCONTRACTOR/CONSULTANT ADDRESS _ j R J O CITY/STATE/ZIP LICENSE Cv/C-57 CI C-61 ❑ D-09 ❑ Other NUMBER p +0 I EXPIRATION DATE hZI 1_207.0 BILLING PARTY: ❑OWNER U CONTRACTOR I I SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING:I"1 General Mineral/Coliform Bacteria(4391)(.1 Dibromochloropropane(4392)CI Arsenic(4393) INTENDED USE L-i Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring IVSoil Sampling/Characterization 0 Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK 0 New Well ❑ Replacement Well 0 Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells I/Soil Boring(s) l #of borings 0 Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump ❑ Pump Replacement CI Pump Repair _ ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method 0 Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point D Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter 0 Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel 0 Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft )Geat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water 0 Bentonite(20%solids) Other Grout Placement Method ❑ Pumped ❑ Free Fall 0 Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other 0 Concrete Pedestal❑Dimensions:Width ft Length ft Thick in 0 Christy Box 0 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 46 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNEDTITLE ✓1�H/il DATE NT ED I Jul. 2019 COUNTY CFj N ENTAL T J C EF NRTMENT L- ,ND - TMENT USE ONLY A4�L� Application Accepted By Date 6 5 Area Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date U WAIVER Received Soil Boring Inspection By /wM�� Date Constructed Well Depth It COMMENTS IV PE SC Received h Amount Permit/ Codes Info B Cash Remitted Date Servic Re uest# Invoice# Well ID# S EHD 43-06 6/11/2019 WELL/PUMP PERMIT