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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 p �� Q � 17G' CITY/ZIP m /' ��JJ Gtt/!w D CROSS STREETS APN��F-r O �� PARCEL SIZE /ZO LAND USE APPLICATION# OWNER NAMEZ_ Z PHONE422 �f,- ryn OWNER ADDRESS AQ/JQQ Q-� Z-7 6-4- �at — CITY/STATE/ZIP CONTRACTOR PHONE 7 CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR/CONSULTANT PHONE + SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP LICENSE /.657 _ C-61 _ D-09 Other NUMBER l!/CJ�(O�� EXPIRATION DATE BILLING PARTY: 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 Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair ew Pump Pump Replacement Pump Repair Raise Well Casing WELL CONSTRUCT O Drilling Method ud Rotary _ Air Rotary Auger Cable Tool Push Point Other Proposed Well Depth_E_zyft Excavation in diameter _ Open Bottom k-"'G-ravel Pack/Gravel Size in diameter Conductor Casing _in diameter / Conductor Casing Depth _"o V ft Well Casing Diameter 41 in Thickness/Gauge/ASTM Sched Steel L-Plastic Stainless Steel Other Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) _ Sand Cement sack mix/7 gal water Bentonite(2 %solids) Other Grout Placement Method !Pumped _ Free Fall _ Other _ Retardant/Accelerator(name) PEDESTAL Installed By Driller Pump Contractor Other Concrete Pedestal _Dimensions:Width ft Length f Thick in Christy Box Stove Pipe PUMP 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. MINIM M 48 HOUR ADVAN OTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209) 953-7697 SIGNE �� / �CC TITLE o /tel jit!/J DATE /� f � A 4 N O R I I I I I I I I I I I I I I I I I I I I I I 1 I I I I I I I I I I i I I I I I I I I I I I EP RTM ENT U E ONLY Application Accepted By Date Area Employee ID# Grout Inspection By Date G, SPECIAL Well Permit Pump Inspection ByiAG�Sw �Cr ^ Z Date / ��i2� WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received ec Amount Permit/Co Info B ash emitted Date Service Request# Invoice# Well ID# EHD 43-06 6/11/2019 WELL/PUMP PERMIT