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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 JOBADDRESS XC-\r-k O - i 1f \ r. �K]. CITY/ZIP WA -tom` �� S_�",It r� D CROSS STREET Ca. .r_t L4 APN PARCEL SIZE �� LAND USE APPLICATION# o A 1 m OWNER NAME L��,i\�.o -._c`- `L1c+�r�•i r_s PHONE OWNERADDRESS � '\ �C�+1 �\Vc�.- 1 CITY/STATE/ZIPV,_iTV.,C w CONTRACTOR \�X CSY^•',s _ C'_1%_-Ml r `lZ, Z C\ PHONE 1 65 CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR/CONSULTANT PHONE SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP LICENSE fJ C-57 CI C-61 L D-09 CJ Other NUMBER EXPIRATION DATE BILLING PARTY: ER LJ CONTRACTOR LJ SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING C1 General Mineral/Coliform Bacteria(4391)f i Dibromochloropropane(4392) 1 Arsenic(4393) INTENDED USE ,t Domestic/Private 'J Irrigation/Agricultural '-1 Industrial ❑Water Quality Monitoring I J Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑New Well LI Replacement Well ❑Well Alteration/Modification 1-1 Other I]Monitoring Well(s) #of wells I I Soil Boring(s) #of borings CI Geotechnical #of borings ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair •tX New Pump ❑Pump Replacement ❑Pump Repair rI Raise Well Casing WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary U Auger ❑Cable Tool ❑Push Point n Other Proposed Well Depth ft Excavation in diameter U Open Bottom ❑Gravel Pack/Gravel Size in diameter C1 Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_in Thickness/Gauge/ASTM Schad C Steel ❑Plastic r Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 Ib bag/5-10 gal water) n Sand Cement sack mix/7 gal water C1 Bentonite(20%solids) ❑Other Grout Placement Method n Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By [I Driller Ll Pump Contractor 0 Other F.I.Concrete Pedestal Dimensions:Width it Length ft Thick in ❑Christy Box Li Stove Pipe PUMP ❑Submersible[]Turbine 11 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 COMPENSATI N LAWS. MINIMUM 48 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)95573-7697 CI SIGNED TITLE LC)'-Gr- DATE R qy�� lie r -10 F49 � RQU�N X20 Ty�" �Hry FNT D E PW M E N T USE O LY Application Accepted By Date G /� Area Employee ID# Grout Inspection By Date 11 SPECIAL Well Permit Pump Inspection By Cw L St w t,4- Q...>, Dale 'I.j') S 1_2°l� Li WAIVER RBC@IVed Soil Boring Inspecti By Dale Constructed Well Depth It COMMENTS WeO Lip z� PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Cods Info B ash Remitted Service Re uest# 1l,x c:;-F EHD 43-06 6/112019 � - � /��/�/, �� WELL/PUMP PERMIT