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WELLIPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 NON-REFUNDABLE PERMIT QQ www.s Ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 3 G CITY/ZIP m fi 'J�G,ta , A �5a31 CROSS STREET y re-) , 3 �'7C) PARCEL SIZE"rLAND USE APPLICAAJI) _jTITIOO�NI# OWNER NAME �',+�3qq ` 1 r PHONan- tmn r1a OWNER ADDRESS 1 CITY/STATE/ZIP CONTRACTOR PH0NB�0 CONTRACTOR ADDRESS CITY/STATE/ZIPd6�_tA 5 SUBCONTRACTOR/CONSULTANT 1A oe A PHONE 41 SUBCONTRACT /CONSULTANT ADDRESS CI /STATE/ZIP LICENSE 57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE (/ BILLING PARTY: ❑OWNER ❑CONTRACTOR D SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING:11 General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE omestic/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 0 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service ell ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pum Pump Replacement ❑ Pump Repair D Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ 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 ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(941b bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water 0 Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fail ❑ Other 0 Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor 0 Other 0 Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe aj PUMP Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft I HEREBY CER IFY 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. 1 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 WORKER MPENSATION LAWS. I U 4 A VANC TICE REQUIRED F R INSP TIONS-PLEASE CALL(209 3- 697 SIGNED TITLE DATE IlLg— \J1T I ILI 44 1 —————— 10 I Ulf.III MM M WEN HEA.TlI II R T A 44 PARTMENT Ur3E NLY � _'� _ �� Application Accepted By Date Area Employee ID# Grout Inspection By ,1 Date ❑ PECIAL Well Permit: Pump Inspection By �ow �ZQ�'�AapLjj Date(Z � ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS �60 - C011Z)6G11D TV wl,Q PE SC Received Ch Amount Date Permit/ Invoice# Well ID# Codes Info Cash emitted Service Request# to-kk Poo EHD43-06 6/11/2019 WELL/PUMP PERMIT