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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 1 to JOB A DRE ��c. '\�G��n,/� 1 CITY/ZIP m CROSS STREET .1 �� AQP/N I� PARCEL SIZE LAND USE APPLICAtTII�ONN# OWNER NAME t//c� (/, li / /[��R' f-!ISL{) PHONE X61 '1H��Ts►lT y OWNER ADDRESS o X D CITYISTATE21P / /�Q CONTRACTOR Yi Jl \(\g� PHONE(�� Q . /)/ 1 ,�t�T CONTRACTOR ADDRESS �yy�6r \t�1� C: CITY/STATE21PSL,i,��. �V SUBCONTRACTORICONSULTANT a 4ti"fr� J .J PHHOOfN\E `, . {J SUBCONTRACTOR/CONSULTANT ADDRESSCITY/STATEIZI R R I AhgAIn- !Y /qfT � LICENSE V C-57 ❑C-61 ❑D-09 ❑Other \ NUMBER\�LI,I EXPIRA11O DATE BILLING PARTY: D OWNER ❑CONTRACTOR ❑SUBCONTRACTORICONSULTANT d DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial D Water Quality Monitoring oil Sampling/Characterization ❑Public Water System If different from Owner. Water System Name Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well D Well Alteradon/Modification ❑Other ❑Monitoring Well(s) #of wells D Soil Borings) #of borings Geotechnical #of borings ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair ❑New Pump ❑Pump Replacement 7 Pump Repair C Raise Well Casing WELL CONSTRUCTION Drilling Method ❑Mud Rotary C Air Rotary 7 Auger ❑Cable Tool 6YPush Point C Other Proposed Well Depth it Excavation in diameter 7 Open Bottom D Gravel Pack/Gravel Size in diameter I I Cond or Casing in diameter / Conductor Casing Depth it Well Casing Diameter in Thickness/Gauge/ASTM Schad 7 Steel 7 Plastic ❑Stainless Steel ❑Other Grout Seal Depth it IV4eat Cement(94/b bag/5-10 gal water) 'I Sand Cement sack mix/7 gal water ❑Bentoni (20%solids) C Other Grout Placement Method plumped C Free Fall D Other C Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor 7 Other U Concrete Pedestal Dimensions:Width ft Length it Thick in L Christy Box L Stove Pipe PUMP I I Submersible I Turbine I 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUIN 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209) 53-769 SIGNED TnLE ✓t��✓�.(C�' DATE 1k ��\ cFi��Nr o °620 qQ� 19 /�FpgRN q4 MF/1'T DIWARIMENT U NLY Application Accepted By Pate Area Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By ,,�.. ''Date ❑ WAIVER Received ''`` Soil Boring Inspection By F RZUate ' 2 Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Permit/ Codes Info Ca h itte Date *qrvjre Re uest# Invoice# Well ID# EHD 43-0e 8/1112019 //..�� j 71/71/ �/ WELL/PUMP PERMIT