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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 I YEAR FROM DATE ISSUED JOB ADDRESSY/ CITY/ZIP m Dl�/�L (2 �� O D CROSS STREET y� APN cella r PARCEL$IZE LAND USE APPLICATION# Opp OWNER NAME �T. -r�D� _ f PHONE �J CCA n OWNER ADDRESS ��(// �� 4f 41510 !°� ` CITY/STATE/ZIP r ^� 5 CONTRACTOR / PHONE CONTRACTOR ADDRESSCITY/STATE/ZIP SUBCONTRACTOR/CONSULTANT _ ��- PHONE SUBCONTRACTOR/CONSULTANT ADDRESS _ CITY/STATE/ZIP LICENSE yC-57 'IC-61 ❑ D-09 ❑ Other_ NUMBER EXPIRATION DATE BILLING PARTY: /`�❑OWNER ❑CONTRACTOR 0 SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural 0 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 0 New Well 0 Replacement Well 0 Well Alteration/Modification ❑ Other 0 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings 0 Geotechnical #of borings ❑ Out-Of-Service Well 0 Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump XPumpReplacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary 0 Air Rotary 0 Auger ❑ Cable Tool ❑ Push Point 0 Other Proposed Well Depth ft Excavation 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 0 Steel ❑ Plastic 0 Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water 0 Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped 0 Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor 0 Other ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box 0 Stove Pipe 44 oc PUMP ubmersible❑ Turbine ❑ Other HP I 2L*7 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. 8 DVANCE NOTICE REQUIRED FOR IN PECTIONS -PLEASE CALL(209)95 469 SIGNED TITLE A DATE �!D IJ /0 �N �LZL M E N T S E ONLY NEAL7H D AENMEN Application Accepted By Date Area Employee ID# Grout Inspection By Date �I SPECIAL Well Permit Pump Inspection By _trfDate LI WAIVER Received Soil Boring Inspection By _ Date Constructed Well Depth ft COMMENTS _ . PE SC Received Vheckg Amount Dat Permit/ Invoice# Well ID# Co4p, info qy.,d Cash Remitted Service Request# EHD 43-06 6111/2019 WELL/PUMP PERMIT