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I:U) U WELLIPUMP PERMIT n 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 ADDRESS4-707 Ln 5 m //// D CROSS STREET PN i PARCEL SIZE Oe LAND USE APPLICATION# OWNER NAME 11n. LILI39&PHONE '` CA OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR PHONE n CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR/CONSULTANT PHONE SUBCONTRACT /CONSULTANT ADDRESS ITY/STATE/ZIP LICENSE -57 ❑ C-61 ❑ D-09 ❑ Other NUMBE EXPIRATION DATE��L BILLING PA TY: ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING:17 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 ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump )&ump Replacement ❑ Pump Repair ❑ 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 .❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Schad ❑ Steel 0 Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cemeni sack m&17 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMPubmersible❑ Turbine ❑ Other HP IN 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 MPENSATION LAWS. I UM 4 H R CE NOTICE QUIRED FO INSP NS -PLEASE CALL(209) 953-7697 SIGNED TITLE DATE AR3 E, OA U N1 O N AA r-N ON T TF_ DE ARTMENT U E NLY Application Accepted ByDate _ --- Area-`�'4' 14( "0- // _ Employee ID#�% Grout Inspection By Date _. D SPECIAL Well Permit Pump Inspection By OiYI(Y/L L �Ir r1\ Date 2o CI WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE Sc Received Check#/ Amount Permit/ Codes Info Cash emitted Date Service Request# Invoice# Well ID# Zoo EHD 43-06 6/11/2019 WELL/PUMP PERMIT