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LTJ\:J WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 NON-REFUNDABLE PERNI[Te- Sjgov.org/ehd PIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS fn CITY/ZIP 5 m CROSS STREET AP _PARCEL SIZE / LAND USE APPLICATION# o OWNER NAME !�{ ) L. HON OWNER ADDRESVO S CITYISTATE/ZIP CONTRACTOR ONE i �v CONTRACTOR ADDRES3CQCITY/STATE/ZIP SUBCONTRACTOR/CONSULTANT A PHONE SUBCONTRAX TORICONSULTANTADDRESS CI /STATE/ZIP LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE BILLING PARTY: ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT DOMESTIC WELL S MPLING:❑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 ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump JWump 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 Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water D 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 PUMP Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft 1 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. M A VANCE OTICE REQUIRED FOR INSP TIONS -PLEASE CALL(209) 3 769 SIGNED TITLE DATE LL I ;HEPAUN L E T EN EP RTMENT U E NLY c Application Accepted By Date Area Employee ID# Grout Inspection By Date 0 SPECIAL Well Permit Pump Inspection By t4C1'(Y.� �c�r r\ Date 2�o i� D WAIVER Received Soil Boring Inspection By Date Constructed Well Depth_ ft COMMENTS PE SC Received Check#/ Amount Permit/ Codes Info B Cash emitted to Se Permit/ Invoice Request# Invoice# Well ID# EHD 43-06 6/11/2019 WELL/PUMP PERMIT