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r WELL/PUMP PERMIT 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 /V rO1 m JOB ADDRESS I o('q AAN�trC 4 Cj !l51� m� S OUI`-y � CITY/ZIP n �7�/� �7 D CROSS STREET ^� APN LO9- OSd -GWPARCELSIZE `•LAND USEAPPLICATIO�Nf#Q^�, 0 OWNER NAME VO'� L��C1� 1 J J � /Ly,/P,H2ONE � — / ! + c r�� OWNER ADDRESS I n h b `�OUIT�I D1VL�^• ��—/"�\ CITY/STATE/ZIP /' l�M1 4f co" ) ��y �✓�� CONTRACTOR Mo s-c 1�O L�rKMi-m- r :77-o • P�H-ON/E— 5ZZ/I—`�G CONTRACTOR ADDRESS J 1 /V I�Ti` J � A CITY/STATE/ZIP SUBCONTRACTOR/CONSULTANT PHONE SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP / �C LICENSE )CC-57 o C-61 UD-09 Li Other NUMBER64Z2-2, EXPIRATION DATE T V' / BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial 15 Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK XNew 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 ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method )<Mud Rotary ❑ Air Rota Ro Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth Excavation _� in diameter ❑ Open Bottom ><Gravel Pack/Gravel Size in diameter LIConductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter-6— in Thick/Gauge/ASTM Sched?�O 01 Steel Plastic ❑ Stainless Steel a Other �fAGrout Seal Depth d Neat Cement(94 lb bag/5-10 gal water) _ Sand Cement sack mix/7 gal water Bentonite(20%solids) rI Other Grout Placement Method Pumped ❑ Free Fall ❑ Other 7 Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ump 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 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. M \\� 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 953-7697 SIGNED u�—.rte` TITLE DATE n 14A ZZ NN E A T F EPrA TM EN Q E NLY >r� Application Accepted By Date V Area Employee ID 6VW Grout Inspection By Date L SPECIAL Well Permit Pump Inspection By f Date L: WAIVER Received Soil Soil Boring Inspection By Date Constructed Well Depth 2, ft CMEN_TSIUM6 'Ai t'5' O 44C_,L SeeWP PE SC Received Check#/ Amount Permit/ Code Ifo B Cash emitted Date Service Re uest# Invoice# Well ID# 0 2 i 3 2D I W 8'3 EHD 43-06 6/11/2019 WELL/PUMP PERMIT