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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 Ln JOB ADDRESSl �� CITY/ZIP � L�fLI(rf � C6330 v �hDCROSSSTREET AP \� PARCELSIZEGLypUADN OWNER NAME �' � t 1� aG �(�I �t t PHONE /� q.�� Ch OWNER ADDRESS �L�1 1/�JL� {`��9_�,(� ��ni le � CITY/STATE/ZIP (1(I [G C -I l 2) CONTRACTOR 1��,\ x�! PHONE. IL-13y CONTRACTOR ADDRESS 1117 CITY/STATE/ZIP WP15t 4,W 1414 ' 60� tQ , AA56(I SUBCONTRACTOR/CONSULTANT l PHONEc/._+, ?� SUBCONTRACTOR/CONSULTANT ADDRESS � �tl(�1 P�t CITY/STATE/ZIP�)_J �`)��G /� ��6 ` LICENSE "P-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE C)" f ! M BILLING PARTY: JLOWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring 'Soil Sampling/Characterization 0 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 '07 of borings ❑ Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rota ❑ Air Rotary tocAuger ElCable Tool ❑ Push Point ❑ Other Proposed Well Depth_ Excavation in diameter ❑ Open Bottom 0 Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic ❑ Stainless Steel 0 Other Grout Seal Depthft f Neat Cement(94 lb bag/5-10 gal wafer) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped Free Fall 9 Other .Jpr1A� � ❑ ear an celerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other 0 Concrete Pedestal❑Dimensions:Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe PUMP ❑ Submersible❑ Turbine 0 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) 953-7697^ SIGNED._- ff\o7 u TITLE y t(� f DATE 2\ I [L)-y 1%4 T10J C N DEPARTMENT USE ONLY C Application Accepted By Date Area Employee ID# Grout Inspection By Date Ll SPECIAL VVell Permit Pump Inspection By Date Ll WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE Sc Received Amount Date Permit/ Invoice# Well ID# Codes Info By Cash Remitted ervice Request# 2 •2 2 S EHD 43-06 6/11/2019 WELL/PUMP PERMIT