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WELUPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 NON-REFUNDABLE PERMIT WWW.S. org/ehd EXPIRES 1 YEAR FROM DATE ISSUED N JOB ADDRESS CITY/ZIP CA (45W m AIACj 'Itn rd. 20t��-() EQpI� CROSS STREET AP ARCEL SI2 LAND USE AnnPrrPrrLI..C````ATIO�Ny#cc` J o OWNER NAME �� l PHON� 0/ 1) �70 �0/��//J�\� 1? OWNER ADDRESS (� [/ CITY/STATEfZIP 'V l/�i'f CONTRACTOR r f 1 T:' 101111 PPH��ONE �0 7�y CI 7 CONTRACTOR ADDRESS 24�5 �WWrI (lY1 CITY/STATEZP �, ICu—Lq SUBCONTRACTOR/CONSULTANT PHONE SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATEIZJP LICENSE r1 C-57 !!C-61 r D-09 ❑Other NUMBER� EXPIRATION DATE /O BILLING PARTY: IiOWNER iI CONTRACTOR SUBCONTRACTORICONSULTANT DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391):1 Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE Id Domestic/Private ❑longation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization D Public Water System If Afferent from Owner Water System Name contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other D Monitoring Well(s) #ofwells ❑Soil Boring(s) #orbonngs ❑Geotechnical #olborings ❑Out-OfService Well El Out-Of-Service Well Renewal D Cross-Connection Repair Y New Pum 0 Pum Replacement r]Pum Repair ❑Raise Well Casing WELL CONSTRUCTION Drilling Method 1.1 Mud Rotary I I Air Rotary I I Auger ❑Cable Tool ❑Push Point El Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size _in diameter II Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic P Stainless Steel ❑Other Grout Seal Depth ft D Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack ma/7 gal water D Bentonite(20%solids) D Other Grout Placement Method 11 Pumped ❑Free Fall LI Other ❑Retardant/Accelerator(name) PEDESTAL Installed By LI Driller D Pump Contractor 0' Other "I VW'r lI Concrete Pedestal❑Dimensions:Width ft Length Thick in 1 Christy Box 11 Stove Pipe PUMP I4 Submersiblel I Turbine ❑Other HP Pump Set_L-.' 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. Iv ;- ui 4d HU AD N EQUIRED FO IN,S/P TION PLEASE CALL(209)953-7697 �. SIGN C TITLE .(/ DATE AN 2 8 2020 ORo�IN COUNTY Fi DE ARTMENT EP RTMENT SE ONLY (Iy"�� Application Accepted By Date� If ?1/0 Area Employee ID# 45 K Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By f Tun<<5l0 Date -L( 1 '� L+ 1 WANER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE Sc Received C Amount a� Permit/ Invoice# Well ID# Co es Info Cas Remitted Service Re uest# EHD4306 6/11/2019 WELL/PUMP PERMIT