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CA � WELL/PUMP PERMIT � SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209� NON-REFUNDABLE PERMIT WWW.S OV.Or /ehd EXPIRES 1 YEAR FROM DATE ISSUED _N JOB ADDRESSf1liC-o' D CROSS STREET APN PARCEL SIZE: LAND USE APPLICATION# ` /1 ro OWNER NAME V U PHONE ,/r 6� /�I F IDA OWNER ADDRESS J _ V /O CITY/$TATE21P--SAA $.��`; CONTRACTOR PHONE L2,01 CONTRACTOR ADDRESS.� 1 ?-q-yk CITY/STATE21P\X^ SUBCONTRACTOR/CONSULTANT�Y� d �yi\��z PHONE �r-1 04 SUBCONTRACTOR/CONSULTANT ADDRESS C�O g nN CITY/STATE/ZiP M Qt'�-3"Pz/c_�g,LJ•C5 LICENSE V67 D C-61 ❑D-09 ❑Other NUMBER,�Q,WIIn166 EXPIRATION DATE BILLING PARTY: ❑OWNER CONTRACTOR ❑ SUBCONTRACTORiCONSULTANT DOMESTIC WELL SAMPLING:D General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Ifftoll Sampling/Characterization ❑Public Water System If different from Owner. Water System Name Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other ❑Monitoring Well(s) #of wells ❑Soil Bodng(s) #of bodngs 1?0"e-otechnical #of borings D Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair D New Pump ❑Pump elplacement 7 Pump Repair C Raise Well Casing WELL CONSTRUCTION / Drilling Method D Mud Rotary C Air Rotary D Auger ❑Cable Tool llPush Point C Other Proposed Well Depth it Excavation in diameter 7 Open Bottom ❑Gravel Pack/Gravel Size in diameter I I Condu or Casing in diameter / Conductor Casing Depth It Well Casing Diameter i7 Thlckness/Gauge/ASTM Sched 7 Steel 7 Plastic ❑Stainless Steel ❑Other Grout Seal Depth_ _ft 190 eat Cement(94/b bag/5-10 gal water) -1 Sand Cement sack m1x/7 gal water ❑Bentonite(20%solids) C Other Grout Placement Methodl015umped C Free Fall Other C Retardant/Accelerator(name) PEDESTAL Installed By D Driller ❑Pump Contractor 7 Other U Concrete Pedestal LIDlmensions:Width It Length ftThick in L Christy Box L Stove Pipe PUMP I I Submersible I Turbine I Other HP Pump Set ft Standing Water Level it 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSUS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH WORKERS COMPENSATION LAWS. MINI M 48 HOUR ADVANCE NOTICE REQUIRED FOR+INSPECTIONS-PLEASE CALL(209)953-7697 RF Ei�iV r SIGNED TITLE \Tf 5-'In titope DATE Vq-® COU O N� ENT 1 1711 P T M E N T US PNLY ��,/ Application Accepted By Date Area Employee I D#�s�t�l A Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received s q Soil Boring Inspection By � 7\ - Date 2'? I Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount PermiU Codes Info Cas Remitted. Date Se ice Re uest# invoice# Well ID# I EHD 43-06 611112019 I`/ ,// WELL(PUMP PERMIT