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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 3 ,v �2 0^) CITY/ZIP 'y'z'"'j m �ICe D CROSS STREET "'1D/J'�LQ�]I t S'//��c� A/P�N/ /0-3 3 I PARCEL SIZE2-Z�IkLAND USE 9APPLLICAATIIO/ONN 1,5--7-7# o OWNER NAME rL, /1 L�tt/1/ (_///1/�••� cPHONE (�O ]/ / J1,5--7-7 Ch CA OWNER ADDRESS !U LNo �/-t nl �i ra•�.•, CITY/STATE/ZIP 6J a C kyy") (114- CONTRACTOR ��(e i�i7C ��1 [TL—� PHO CONTRACTOR ADDRESS / /V —14,4/7.4 gC CITY/STATE/ZIP SUBCONTRACTOR/CONSULTANT PHONE SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP LICENSE C-57 ❑ C-61 ❑ D-09 -1 Other NUMBER EXPIRATION DATE BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) =LTENDED PQ omestic/Private ❑ Irrigation/Agricultural CI Industrial -]i Water Quality Monitoring LiSoil Sampling/Characterization CI 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 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings r Geotechnical #of borings Out-Of-Service Well El Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCT ON Drilling Method 'J Mud Rotary ❑ Air Rotary. LI Auger ❑ Cable Tool -I Push Point Ll Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom i Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched F] Steel ❑ Plastic Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other L Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersible❑ Turbine ElOther HP Pump Set D ft Standing Water Level ft 1 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. M—Mft UM 48 HOUR AD CE T E EQUIRED FOR INSPECTIONS -PLEASE CALL(209 953-7697 SIGNEDTITLE OW IIGL DATE 2 t Nr A . FO 19 R T P TMENT U§KE ONLY Application Accepted By Date [ Area Employee ID#� Grout Inspection By Date PECIAL Well Permit Pump Inspection B Ins 1'5cec� Date ( ` 0 WAIVER Received Y , at4,� ?� G-IaL �•'ti Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS O fes- -: PE Sc Received Check#/ Amount Permit/Co s Info By_ Cash emitted Date Service Request# Invoice# Well ID# c3 L 2t �EH(�D�3-06 6/11/2019 ,` �� WELL/PUMP PERMIT `7, 'GG )I P W SJv'L41..