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a � WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 NON-REFUNDABLE PERMIT www.§jgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 1.9 2 S 1 __154viientAl CITY/ZIP S�Q 53Z6 rn CROSS STREET_I (jj nZ o APN 2 ��Q ��i.,b PARCEL SIZE G.C� CLAND USF APPLICATION# p -- OWNER NAME �V A Sr--J-=1Sd1_�r----Ar%jr_ �Q_Ay_--_ -- PHONE to 0 vum p c OWNER ADDRESS \ UZ$1 � L>/1 �1� {Z d, — CITY/STATE/ZIP CG♦</!/y�^� ftj C� J.2y CONTRACTOR MA4-etllf < ,rIL^,HIVI PHONE '52Z 1g2(¢ CONTRACTOR ADDRESS 11ot /4_( o eA _ CITY/STATE/ZIP / *II,.S 7 y Cy y535 I SUBCONTRACTOR/CONSULTANT PHONE- SUBCONTRACTOR/CONSULTANT ADDRESS _ CITY/STATE/ZIP LICENSE X C-57 CI C-61 ❑ D-09 11 Other NUMBER 66SP1_7— EXPIRATION DATE BILLING PARTY: i OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING,:; i General Mineral/Coliform Bacteria(4391)I Dibromochloropropane(4392)! Arsenic(4393) INTENDED USE .. Domestic/Private ❑ Irrigation/Agricultural 0 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 0 New Well LAeplacement Well 0 Well Alteration/Modification ❑ Other 0 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings n Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New PUMP ❑ Pump Replacement 0 Purnp Repair 0 Raise Well Casing WELL CONSTRUCTION Drilling Method *ud Rotary ❑ r R ❑ Auger ❑ Cable Tool ❑ Push Point 0 Other Proposed Well Depth_ �ftt cavation 12 �� in diameter 0 Open Bottom XGravel Pack/Gravel Size 1±12 in diameter 0 Conduc r Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in1,�I Gauge/ASTM Sched� El Steel Plastic 0 Stainless Steel 11 Other Grout Seal Depth"'"Tt�eat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mW7 gal water XBentonite(20%solids) ❑ Other Grout Placement Method,Pumped ❑ Free Fall 0 Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By i.l Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe f PUMP 0 Submersible Ll Turbine 0 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. 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209)x/953-7697 9 SIGNED TfTLE_�G.�!`11l DATE%IP M )M a /VNO Fp U/1 77 T FNr D P A R TV ON Y Application Accepted By Z�tDate /(01 Area Employee ID# /t Inspection _ Date Grout BY �L Well Permit _ -- / Pump Inspection By _. Date_ _ WAIVER Received "� Soil Boring Inspection By J Date Constructed Well Depth ft COMMENTS PE Sc Receivedheck# Amount Date Permit/ Invoice# Well ID# Codes Info B Cas Remitted Service Request# - D tit-{ 20 -i°I WPOO4010S _ 3 a 10.11 Wf DO L4 01 S EHD 43-D6 6111/2019 WELL/PUMP PERMIT