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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 EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS Pou _ CITY/ZIPyl I OI V i Gil 02,0 m m ft\jA r b r.1 b CROSS STREET f2 _77_��.rr^^,, A. ACPIN 2 1 -1 b O J PARCEL SIZE LAND USE APPLICATION# V-1 AOWNER NAME (PH/ONE_Z,_Oa J !n/91Dc� ru'n OWNER ADDRESS riOQQN __ _ t CITY/STATE/ZIP �7 V{ t! G�-1�v�v CONTRACTOR _ V116 I 11 - 1 �A PHONNEE ✓2Z^�/N 2,19 �j CONTRACTOR ADDRESS "I � 'b� CITY/STATE/ZIP {•'WAD- �/��jj► • 41;/3 it� SUBCONTRACTORICONSULTANT PHONE U4' ✓2Z'142Y SUBCONTRACTOR/CONSULTANT ADDRESS CITTY�/STATE/ZIP _ ']- LICENSE YC-57 D C-61 Ll D-09 U Other NUMBER]C V ClQ ___ EXPIRATION DATE ' • �O`� BILLING PARTY: OWNER i i CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)1 1 Dibromochloropropane(4392) Arsenic(4393) INTENDED USE D Domestic/Private Xirrigation/Agricultural D Industrial ❑ Water Quality Monitoring D 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 17 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings 1 Out-Of-Service Well ❑ Out-Of-Service Well Renewal D Cross-Connection Repair n New PUMP U Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method)(Mud Rotary n Air Rotary n Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth.Kao ft Excavation a in diameter D Open Bottom �Gravel Pack/Gravel Siz _kZ_in diameter n Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched 100 ❑ Steel Plastic D Stainless Steel ❑ Other Grout Seal Depth -S ft n Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water NtlilBentonite(20%solids) D Other Grout Placement Method)(Pumped D F fee Fall D Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By D Driller XPump Contractor D Other D Concrete Pedestal❑Dimensions:Width ft Length ft Thick in D Christy Box D Stove Pipe f PUMP ❑ Submersible0 Turbine U 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. M11=8 HOUR APVAt,4f.E NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 963--7n697 SIGNED -� TITLE_ � DATE 17'• s o�. z )Aoulu N E DE A R T M E N T U E 'ONLY Application Accepted By D &"W ate Area L� _ Employee ID# Grout Inspection By Date DSPECIAL Well Permit Pump Inspection By Date WAIVER Received Soil BoringInspection By Date Constructed Well De th ft C MMENTS v PE Sc Receivedhec Amount Date Permit/ Invoice# Well ID# Codes o B ash emitted Service Re uest# 1 Iq 3 cs EHD 43-06 6/1112019 WELL/PUMP PERMIT