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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTii DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 NON-REFUNDABLE PERMIT -- _ wwwsjgOV.org/ehd _ EXPIRES 1 YEAR FROM DATE(ISSUED JOB ADDRESS i �r /e d• CITY 21P M aVl fi�C 0- ` (p m CROSS STREET So V r L'/a,4 APN_;Z-0(J"0q0"L r 0-0e1P0'RCEL SIZE11 LAND USE APPLICATIONn#;� / A OWNER NAME �/{�/ d I�r ll I, _LL1---- -----'— —'' 5f PHO_ 6,j N/E 1,, d�f� OWNER ADDRESS (,ST !/�/ �, _ CITY/STATEIZIP-�4�L J 10 r Q_, ff E'?/T CONTRACTOR PHONE CONTRACTOR ADDRESS _mil CITY/ STATE/Zip „ -- r- — -- SUBCONTRACTORICONSULTANT _ — _ PHONE_ SUBCONTRACTOR/CONSULTANT ADDRESS . (a46a CITYISTATE/ZIP '- LICENSE f 1 C-57 `, C-61 D-09 Other NUMBER EXPIRATION DATE BILLING PARTY: OWNER 0 CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING:a General Mineral/Coliform Bacteria (4391) ' Dibromochloropropane(4392) .' Arsenic(4393) INTENDED USE X Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization 1 Public Water System — 11 rl:frerert Prom Owner _ Water cyzi^Name Cnntari Name or Phone Number TYPE OF WORK )(New Well ] Replacement Well Well AlteratlonlModification Other _-- _ l-I Monitoring Welln #4 or bonngs s) -#of wells Soil Boring(s1 Geotechnical—_---_-----1 of bor'(O��`IX�_, n I I Out-Of-Service Well I I Out-Of-Service Well Renewal i Cross-Connection Repair New Pump 1! Pump Replacement Ct Pump Repair Raise Well Casing_ Jp N N J WELL CONSTRUC ON H �R�MF DUNS. Drilling Method r' Mud Rotary a Air Rotary Auger 11 Cable Tool l_. Push Point D Other H EPgpNT�C Proposed Well Depth-14--c/ ft Excavation in diameter I Open Bottom _ Gravel Pack/Gravel Size In diameteM NT 11 Conductor Casing in diameter / Conductru Casing Depth ft Well Casing Diameter (0 in Thickness/Gauge/ASTM Schad_�!'Q _ _1 Steel X Plastic -1 Stainless Steel J Other Grout Seal Depth app ft 1, Neat Cement(94 Ib bagl5-10 gal water) Sand Cement sack mixl7 gal water Bentonite(20%solids) -1 Other _ Grout Placement Method U Pumped X Free Fall 1 Other _I Retardant I Accelerator(name) PEDESTAL Installed By � Driller Pump Contractor Other` — t1 Concrete Pedestal JDimensions Width ft Length ft Thick- in .i Christy Box ! Stove Pipe Submersible Turbine i 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. IMMIIV UM 48 H01!.R ADV NOTICE REQUIRED FOR INSPECTIONS PLEASE FALL (2W953-7697(� SIGNED j� .� C�a (. Y t1� �// TITLE ©GU/ /� DATE 7 2 Z I 1�_ I — I I i PAR TMENT US E NL Y Application Accepted y Date e Area _ �Lv/ Employee ID# Final Inspection By Date 4124// ❑ SPECIAL PERMIT-Approved by Character of Soil to epth of 3 Ft: Pit/Sump Soil Character: _ COMMENTS PE SC Received Chad Amount Permit/ Code INFO By _ asi emitted Date Service Request# Invoice# Permit ID# ZS io I W 0 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 4/14/18