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WELL/PUMP PERMIT SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE=-STOCKTON CA 95205-6232 (209)468-3420 NON-REFUNDABLE PERMIT _WWW•Sjov•org/ehd EXPIRES 1 YEAR FROM DATE ISSUED JOBADDRESS �'✓7V`—� CITY/ZIPm N-F1 bW-427 ST Z _ ��J 3 Au�,�s D CROSS STREETAP/N I'}��✓~-��QI 00� OD PARCEL SIZE' •� LAND USE APPPLICAATI/O,NJ# /y': o OWNER NAME J/✓��+V^!'(! �7 �1J�5'/N1 C� _ PHONE17/o//f7 _(C/(7 — / 34I N /TJ///_��tt�JJJ...JJJ��. ��j/�/ OWNER ADDRESS Iq �l q r ��']�`�/" � y� CITY/STATE/ZIR//✓ &7VAJj/ /�Q�v -/� CONTRACTOR �!/r �� —�"►`G' PPHO-PHONE —M(F� 770 CONTRACTOR ADDRESS z 33 A,� �J�� CITY/STATE/ZIP_•✓T(�-.f♦OJV 2�7J(L7 C�� C�� SUBCONTRACTOR/CONSULTANT y��OA II(AC—c- 7AC--NSG/?�_�Qt OGhfT� _ PHONE //, ✓,7 /-d/ 3/Z SUBCONTRACTOR/CONSULTANT ADDRESS 36 _ 'Yy�'"— 'I '` CITY/STAATE/ZIP `+''+jj elLICENSE %C-57 D C-61 0 D-09 L1 Other NUMBER �Q ` D EXPIRATION DATE_/!0—e7o BILLING PARTY: OWNER I,CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/AgricLlltural ❑ Industrial ❑ Water Quality Monitoring Soil Sampling/Characterization D 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 Borings) 6 #of borings )•Geotechnical _#of borings n Out-Of-Service Well ❑ Out-Of-Service Well Renewal El Cross-Connection Repair �15-550� ❑ New PUMP ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary Auger D Cable Tool ❑ Push Point ❑ Other Proposed0*0 Depths V ft Excavation —� in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter sp/L A"v A�D Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel 11 Plastic D Stainless Steel ❑ Other Grout Seal Depth E—^_ ft X Neat Cement(94 Ib bag/5-10 gal water) F1 Sand Cement_ sacR rnix/7 gal water ❑ Bentonite(20%solids) ❑ Other 1LOUT QJ XC01 D W17i &- Grout Placement Method fl Pumped ❑ Free Fall Other _ ❑ Retardant/Accelerat r(name) PEDESTAL Installed By I Driller - ❑ Pump Contractor ❑ Other (� ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe • PUMP r1 Submersible❑ Turbine ❑ 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 COMPENSATION LAWS. MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS PLEASE CALL(209)953-77697 �y� SIGNED _ TITLE �i ijl�^^`�� DATE ti V1 te — - Pikh 32 IsQ N F N E A TMENT SE ONLY ��/)4Q./� Application Accepted By D'to lk� Z� Area–�� Employee ID# jy�V""' Grout Inspection By Date SPECIAL Well Permit Pump Inspection By T Date WAIVER Received Soil Boring Inspection By . _ Date Z� Constructed Well Depth ft COMMENTS PE SC Received Che Amount Permit/ Codes Info B Cash Remitted Date Service Re uest# Invoice# Well ID# / - — 511, 113 Zp vs P �— EHD 43-06 6/11/2019 WELL./PUMP PERMIT