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A WELUPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHDEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 NON-REFUNDABLE PERMIT .S www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED e9 Lz Ln JOB ADDRESS C117 0 -7 CITY/ZIP 'A G 64 G L m CROSS STREET Z/ �J�� A D J_ APN!/5D—ift) � I� PARCEL SIZE `'4 'LAND USE APPLICATION# o OWNER NAMEQ�/ PHH�ONE /./J -9j�/�,S V / Cn m �! � OWNER ADDRESS l rr s �� 19 t /� CITY/STATE/ZIP 7/Z C//1� CONTRACTOR �/ C OC, 177� /PHONE_( Q/o / �/!�✓y/�� ?lC� CONTRACTOR ADDRESS ' ��J�yJ/Y/�/II' J? r ) CITYISTATEIZIP SUBCONTRACTOR/CONSULTANT PHONE SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP 1 LICENSE XC-57 0 C-61 ❑ D-09 ❑ Other NUMBER7.)'J.)' ab EXPIRATION DATE BILLING PARTY: 0 OWNER 0 CONTRACTOR 0 SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring 0 Soil 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 0 Monitoring Wells) #of wells 0 Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service Well 0 Out-Of-Service Well Renewal ❑ Cross-Connection Repair XNewPump 0 Pump Replacement 0 Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger ❑ Cable Tool ❑ Push Point 0 Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 0 Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Schad 0 Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft 0 Neat Cement(94 Ib bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) 0 Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By 0 Driller 0 Pump Contractor ❑ Other 0 Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box 0 Stove Pipe PUMP ❑ Submersible❑ Turbine o 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. UM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209)95A-76971 i SIGNED_ / TITLE DATE � v --+14+++-H--H4� r U T A MNT U E O LY Q Application Accepted By Date Area l Employee ID Grout InspectionBy Date ECTAL Well Permit Pump Inspection By 9yQ�� Date I? CI WAIVER Received Soil Boring Inspection By Date ` Constructed Well Depth ft COMMENTS PE SC Received eck#/ Amount Date Permit/ Invoice# Well ID# Codes Info Rv Remitted Service Request# EHD 43-06 6/11/2019 WELL/PUMP PERMIT