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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 JOB ADDRESS ' 0 I _ Ca � //�� 1141 CITY/ZIP / V /ar4er 4$34346 CROSS STREET OWNER NAME APN Z2� ' p3 d 7a PARCEL SIZE LAND USE APPLICATION # OWNER ADDRESS CONTRACTOR CONTRACTOR ADDRESS SUBCONTRACTOR/CONSULTANT SUBCONTRACTOR/CONSULTANT ADDRESS LICENSE 7 C-57 ❑ C-61 El D-09 11Other BILLING PARTY: CONTRACTOR PHONE I S'/1� CITY/STATE/ZIP /V1Gtx.44CGf 'j� PHONE J ZC �J 2 / � CITY/STATE/ZIP ajipr b i `nGt CITY/STATE/ZIP_ NUMBER PHONE EXPI SUBCONTRACTOR/CONSULTANT RATION DATE !!J— 3 U� Z / DOMESTIC WELL SAMPLING: _ General Mineral/Coliform Bacteria (4391) � Dibromochloropropane (4392) Arsenic (4393) INTENDED USE mestic/Private ❑Irrigation/Agricultural 11 Industrial El Water Quality Monitoring El Soil Sampling/Characterization ❑ Public Water System If different from Owner: TYPE OF WORK �leW Well ❑Replacement Well ❑ Monitoring Well(s) # of wells Li Out -Of -Service Well 11 New Pump 11 ent Water System Name ❑ Well Alteration/Modification ❑Other ❑ Soil Boring(s) Contact Name or Phone Number # of borings ❑Geotechnical ❑ Out -Of -Service Well Renewal Ll Cross -Connection Repair ❑ Pumn Repair 11Raise Well Casinq # of borings WELL CONSTRUCTION Drilling Method NMud Rotary 11Air Rotary ❑ Auger ❑ Cable Tool 11Push Point 11Other Proposed Well Depth 20 0 ft Excavation f c/ in diameter ❑Open Bottom LGravel Pack/Gravel Size in diameter, [IConductor Casing in diameter / Conductor Casing Depth l ft Well Casing Diameter � in Thickness/Gauge/ASTM Sched �_ Li Steel lastic 11 Stainless Steel 11 Other Grout Seal Depth % 6 0 ft 11Neat Cement (94 lb bag/5-10 gal water) and Cement >entonite (20% solids) 11Other Grout Placement Method �IVumped ❑ Free Fall LiOther 11Retardant / Accelerator (name) Installed By El Driller hump Contractor 11 sack mix/7 gal water Other ❑ Concrete Pedestal ❑Dime ions: Width __ ____ ft Length _ ft Thick in ❑Christy Box ❑Stove PUMP ❑Submersible[] Turbine 11 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. MI 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7Q697 1 Q SIGNED o TITLE (Z�hO� DATE ��/ � / Application Accepted Grout Inspection Pump Inspection _, Soil Boring I,solknse`c/tion By COMMENTS �,1 ��/ fm M By 4J` n MENT U E ONLY Date � � Area Employee ID# "` Date PECIAL Well Permit Date �"'fia WAIVER Received Well Depth ft ll� d�Ar � 7 ` ' EHD 43-06 6/11/2019 WELL /PUMP PERMIT 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. MI 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7Q697 1 Q SIGNED o TITLE (Z�hO� DATE ��/ � / Application Accepted Grout Inspection Pump Inspection _, Soil Boring I,solknse`c/tion By COMMENTS �,1 ��/ fm M By 4J` n MENT U E ONLY Date � � Area Employee ID# "` Date PECIAL Well Permit Date �"'fia WAIVER Received Well Depth ft ll� d�Ar � 7 ` ' EHD 43-06 6/11/2019 WELL /PUMP PERMIT EHD 43-06 6/11/2019 WELL /PUMP PERMIT