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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 S www.S ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED Ln JOB ADDRESS 9347 V� �� I��mfC� Ove. CITY/ZIP /(C1L✓ cis-37(, m / Q D CROSS STREET C��h�1 I APN 13/`'DJ PARCEL SIZE LAND USE APPLICATION# v J� jj 1 ` m OWNER NAME Rei G,e.) /��/�c:(rInI?7_ PHONE J --sc; OWNER ADDRESS 70 PCJP, liffcle_ CITY/STATE/ZIP CONTRACTOR �7 VJ T'1�'! PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR/CONSULTANT PHONE SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP LICENSE C-57 _. C.A31 :1 D-09 ❑ Other NUMBER EXPIRATION DATE BILLING PARTY: 4OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) INTENDED USE ;(Domestic/Private ❑ Irrigation/Agricultural G Industrial - Water Quality Monitoring I- 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 -1 Other G Monitoring Well(s) #of wells Soil Boring(s) #of borings j Geotechnical #of borings Out-Of-Service Well Out-Of-Service Well Renewal ;-, Cross-Connection Repair New Pum ❑ Pump Replacement Pump Repair E Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary -! Air Rotary -i Auger ❑ Cable Tool Push Point -i Other Proposed Well Depth ft Excavation in diameter 1 Open Bottom - Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel L Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft El Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) Other Grout Placement Method J Pumped ❑ Free Fall Ei Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By A Driller ❑ Pump Contractor i-i Other Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP X Submersible❑ Turbine ❑ Other HP S 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 COMP TION LAWS. !:71DVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 SIGNED TITLE ��/ 9 1c DATE ��/ O C EP RTMENT US_E ONLY FNT Application Accepted By Date 3 Z 0 zb Area �� Employee ID# k-t r0)7 Grout Inspection ` Date 11SPECIAL Well Permit Pump Inspection By Ric ��Ai�Z Date ❑ WAIVER Received Soil Boring Inspection By Date Construe d Well Depth ft COMMENTS �ee vJ00 OSSA Csf 001V11f IF b�uA s+,r4 /t p J PE SC Received Ch k#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# EHD43-06 6/11/2019 WELL/PUMP PERMIT