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WELLIPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 NON-REFUNDABLE PERMIT www.s Ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED Ln JOB ADDRESS .! 11 CITY/ZIP ��e( e p� !� `f� ((��(( m CROSS STREET a� IlJ Vta APN �,2r '�` U-V` PARCEL SIZE kQ.�N ND USE APPLICATION# p I� 1 X OWNER NAME „ �� 1 �tG.�-1�� PHONE ryi� OWNER ADDRESS uj "e 1F 1 w, CITY/STATE/ZIP CONTRACTOR V 2_Out r(A /� PHONE CONTRACTOR ADDRESS 11 ",)3 r� hlrl f ( IN—yT CITY/STATE/ZIP "vA- C `1 5219 f, 7` — SUBCONTRACTOR/CONSULTANT 1�),tAN\(ike tAW I AY,��ejp PHONE SUBCONTRACTOR/CONSULTANT ADDRESS GOD a amu- za\ aw CITY/STATE/ZIP �z,"m,PjyrY7(� 9S LICENSE )9.C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER:7 20 COL\ EXPIRATION DATE 9)'01 0 BILLING PARTY: WNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring )(Soil 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 Wells) #of wells ❑ Soil Boring(s) #of borings Geotechnical_ #of borings ❑ Out-Of-Service Well ❑-Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pum ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depthe2—D _ft Excavation 6 in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size In diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Sea[ Depth �2 b_ft ,Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water ❑ Bentonite(20%solids) ❑ Other — Grout Placement Method ❑ Pumped A Free Fall Other��YtR& l Wtfd- da ccelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ 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 NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)/953-7697' SIGNED (LO ? � TITLE ' DATE_ /T L(✓ZF� E � N EP RTMENT SE ONLY Application Accepted By _ Date Area d0mployee ID# � Grout Inspection By _ Date ❑ PECIAL Well Permit Pump Inspection By Date LI WAIVER Received Soil Boring Inspection By b Date 12,02,0 Constructed Well Depth ft COMMENTS PE SC Received QLERkW Amount Permit/Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# I UI 0 EHD43-06 6/11/2019 WELL/PUMP PERMIT