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s ` ° WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 NON-REFUNDABLE PEERMIT! act WWW.s Ov.or /ehd r��►EXX`P�IRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 267y I C) LD \1` ' CITY/ZIP 1 0504 C� � _ m CROSS STREET _ APN ��y�oVlr J PARCEL SIZE21,a LAND USE APPLICATION# '/ ,10 O n A X OWNER NAME PHONE(�510 3 CeA N OWNER ADDRESS & AQ F.+ V CITY/STATE/ZIP ��3I�� Ca CjwetV ' CONTRACTOR _ PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR/CONSULTANT _ _ _ PHONE SUBCONTRACTOR/CONSULTANT ADDRESS _ CITY/STATE/ZIP LICENSE ❑ C-57 LI C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE BILLING PARTY: 1 OWNER I CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391)1 Dibromochloropropane(4392); Arsenic(4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural 0 Industrial D Water Quality Monitoring ❑ Soil Sampling/Characterization 0 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 ❑ $oil Boring(s) #of borings ❑ Geotechnical u of borings Ll Out-Of-Service Well VOut-Of-Service Well Renewal EI Cross-Connection Repair D New Pump ❑ Pump Replacement 0 Purnp Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary D Auger D Cable Tool ❑ Push Point D Other Proposed Well Depth ft Excavation in diameter 0 Open Bottom ❑ Gravel Pack/Gravel Size in diameter 0 Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter^ in Thickness/Gauge/ASTM Sched 0 Steel EI Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth_ ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water 0 Bentonite(20%solids) 0 Other Grout Placement Method ❑ Pumped 0 Free Fall ❑ Other 0 Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor 0 Other D Concrete Pedestal❑Dimensions:Width ft Length it Thick in ❑ Christy Box ❑ Stove Pipe PUMP ❑ SUbmersiblep Turbine ❑ Other HP PUMP Set it Standing Water Level _ it HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAI' 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, IM HOUR ADVANCE NOTICE REQUIRED FO, INSPEC- TIONS -PLEASE CALL(209)9 3 'Z6!9,7 SIGNED TITLEDATE`' JC OkC C EN r E P - TMENT U E 5VNLY Application Accepted By _ Date Area Employee ID#AMOA141 LLwW Inspection By _ Date PECIAL Well Permit Pump Inspection By Date _ WAIVER Received Soil Boring I spection By Dale Constructed Well Depth ft C MENT r SC Receive Chec / mount Permit/ 7 �( Codes Into By i Cash Rpmitted Date Service Re uest# Invoice# Well ID# KQ 00,10 15 4 EHD43-06 611/2019 \ 20� / / �� q43 WELL/PUMP PERMIT