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1N1�-1 q c�17-) WELUPUMP 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 C� f A n N JOB ADDRESS 2 I C 2, �T, Spans Bl vd . CITY/ZIP S to C (`to✓1 m II� D CROSS STREET ��()( t N •��. a✓1�5 APN t•' I 0 L I��L C IC/��GUL_PARCEL SIZE >>5�J LAND USE A/PPLICATIO(N�# S OWNER NAME l c, VVW✓1 ��1�It �/I;�L I�?(/�yE LP C./C l-rr�ch2 ��uMiT661( C1(, PHONE \2o, �CTj� -04{ 4- uo'i OWNER ADDRESS h 2- 5 V Q. •r aLrc I� ^rA"� ??.- J CRY//STTATE21P >�lto c[l(k�v(� CA 2S 2-t CONTRACTOR C'(r-CLC�✓1 �yiS✓L I(LI//ttiLS I q� /Y,2',� O �1.L`{S f',f it /17�j(/� 5 PHONE \�j )�6 7 — � f CONTRACTOR ADDRESS it 02 1✓l G(IkS e r`+rti l W C CITYISTATE21P Loci,, CA (I S-2-41) SUBCONTRACTOR/CONSULTANT 14//N PHONE 1 WA SUBCONTRACTOR/CONSULTANT ADDRESS _ -i.`L/� _ _ ICIT/Y,/STATEIZIZIP LICENSE 2(C-57 i C-61 I I D-09 ❑ Other NUMBER EXPIRATION DATE �/� ✓fity' BILLING PARTY: I OWNER ❑CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: L General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)C Arsenic(4393) INTENDED USE Domestic/Private I I Irrigation/Agricultural I` Industrial Water Quality Monitoring I)Soil Sampling/Characterization Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK New Well I_I Replacement Well ❑ Well Alteration/Modification ❑ Other i-1 Monitoring Well(s) #of wells Soil Boring(s)_ _ #of borings 'Geotechnical I I of borings Out-Of-Service Well I I Out-Of-Service Well Renewal Cross-Connection Repair New Pump I i Pump Replacement ❑ Pump Repair Raise Well Casing WELL CONSTRUCTION Drilling Method )(Mud Rotary Air Rotary X Auger . j Cable Tool ❑ Push Point _I Other Proposed Well Depth 15 -50 [ ft Excavation b in diameter 11 Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in I Thickness/Gauge/ASTM Sched ❑ Steel 1-1Plastic 1 Stainless Steel ❑ Other Grout Seal Depth - '5!O ft i<Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement sack mW7 gal water -1 Bentonite(20%solids) ' Other Grout Placement Method I': Pumped -I Free FallOther 7 Retardant/Accelerator(name) PEDESTAL Installed By C Driller Pump Contractor Other ❑ Concrete Pedestal Ll Dimensions:Width ft Length ft Thick in Christy Box 1 Stove Pipe PUMP ❑ Submersible❑ Turbine ❑ 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. MINIMUM 48 HOUR ADVANCE NO I E IRED FOR INSPECTIONS -PLEASE CALL(209)953-7697 SIGNED l/V({. ,vt ft,GL TITLE �t - FPI(rLV\�1'2 ' DATE C'L 15 Pp-at C- Wo s L AT 4A, V v ^ O� PA TMENT USE N L Y Application Accepted By Date Area Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By 44 4 Date WAIVER Received Soil Boring Inspection By _ Date 723 210, Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info By Cash Remitted Service Request# Z' EHD 43-06 6/11/2019 WELL[PUMP PERMIT