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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 l!—f ✓do JOB ADDRESS CITY/ZIP m 7 D CROSS STREET ��►/� �� APIN�� 7U�7 PARCEL SIZE R Z—LAND USE /►A/P�PLICATION#2 A OWNER NAME ►Lt///JI<� /�l,� //�� PHON,E�.�{/�Lq-6q3—q5�q N OWNER ADDRESS 1100:70- ��/JG/f� I ) li�t;-(,/,C /�/pC ITY/STATE/ZIP CONTRACTOR mt(/Y��/U,(//l V� Ll�l[.C.[l/� G(//�/��J f�'C( ' PHONE � /L7 CONTRACTOR ADDRESS�� /� Y,ID� CITY/STATE/ZIP �./�J///�7 V_ SUBCONTRACTOR/CONSULTANT C14 4 PHONE i2� 144 SUBCONTRACTOR/CONSULTANT ADDRESS �lJ CITY/STATE/ZIP / LICENSEC-57 11C-61 [ID-09 El Other NUMBER9�a . EXPIRATION DATE �t BILLING PA TY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ 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 ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings 0 Out-Of-Service II ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point i.i 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 1iSteel ❑ 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 ❑ Concrete Pedestal El Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersible❑ Turbine ❑ Other HP= Pump Set=ft Standing Water Level ft I HEREBY CER IFY 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 WORK E COMPENSATION LAWS. MI 9NC NOTICE REQUIRED FO INSPE ONS -PLEASE CALL(209 9 3-7697 SIGNED TITL a4jA DAT tl / C TIS N E T I Ell I k.._/—— I I ^ D ARTMENT USE O ALL�Y Application Accepted By Date �> Zv Area Employee ID# Grout Inspection By Date SPECIAL Well Permit Pump Inspection By �"'r\LA\:. Date �.�Z� 'Z WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE Sc Receivedheck#/ Amount Permit/Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# 7 7 EHD 43-06 6/11/2019 WELL/PUMP PERMIT