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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 EXPI ES 1 YEAR FROM DATE ISSUED JOB ADDRESS � Na CITY/ZIP m rn CROSS STREET A APN [/J�/"' PARCEL SIZE��LAND USE APPILIICCATIONG#J OWNER NAME �1�/{/ C�y�,OcJ(� PHONE /PP2 [ J OD rn OWNER ADDRESS ��,"�Z CITY/STATE/ZIP -71 7 CONTRACTOR ' Y BOSS /L! !/`'t PHONE,FJ CONTRACTOR ADDRESS -7g CITY/STATE/ZIP Ze— �Q131 ZZ, — SUBCONTRACTOR/CONSULTANTLl C 7/n�� V��yA PHONE C� `? �j2-J SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP LICENSE �-57 ❑ C-61 ❑ D-09 Other NUMBER :3 77J7�-r EXPIRATION DATE �7 J BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE omestic/Private -- Irrigation/Agricultural nIndustrial i Water Quality Monitoring Li Soil Sampling/Characterization ❑ Public Water System ```___��/If'''different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK 7Ivew Well ❑ Replacement Well 1-1WellAlteration/Modification 7 Other C Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings F. Out-Of-Service Well ❑ Out-Of-Service Well Renewal i Cross-Connection Repair New Pump ❑ Pump Replacement ❑ Pump Repair -I Raise Well Casing WELL CONSTRUCTION Drilling Metho;IZ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool I Push Point is Other Proposed Well Depth� <-C) ft Excavation in diameter Open Bottom P<Gravel Pack/Gravel Size in diameter u Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter K in Thickness/Gauge/ASTM Sched -2—V0 I I Steel >.Olastic ❑ Stainless Steel ❑ Other Grout Seal Depth /r71 ft ❑ Neat Cement(94 lb bag/5-10 gal water) >Sand Cement -4 O ' sack mix17 gal water I Bentonite(20%solids) ❑ Other Grout Placement Metho&�4 Pumped ❑ Free Fall ❑ Other a Retardant/Accelerator(name) PEDESTAL Installed By Driller ❑ Pump Contractor 11 Other I- ConcretePedestal[]Dimensions:Width ft Length ft Thick in _I Christy Box ❑ Stove Pipe PUMP ,e Submersiblel l 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 HO RA ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209) 953-76/9�7 / SIGNED /�Vl /r"_ TITLE VW ' DATE C' T Q I c U1 TY E V R N—flu LT 4 NT D PrA TMENT US'eE /N LY Application Accepted By Date C AreaW4� Employee ID#� Grout Inspection By Date SPECIAL Well Permit Pump Inspection By Fsctr��SC� Cmc c.�`r ( . t Date Zl/t(t'2'2D WAIVER Received Soil Boring Ins e�ctionn Date ConstruMdd Well Depth ft COMMENTS — L�ILI�S '1AZ PE SC Received Check#/ Amount Permit/Codes Ifo Cash mitted Date Service Request# Invoice# Well ID# z liqWptoov3 92- jq 4J L q r� l 3 E D 43-06 6/11/2019 WELL/PUMP PERMIT