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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.S Ov.or /eh'd✓ EXPIRES 1 YEAR FROM DATE ISSU D I 3.53 W JOB ADDRESS _ 5 (4 / . 1� AVf-- CITY/ZIP / CA S m I D CROSS STREET c��. �Gz e APN 2-1-3) 0 PARCEL SIZE LAND USE APPLICATION# A OWNER NAME ` a �5 Y` PHONE /] 1y, ��' " OWNER ADDRESS I , ` CITY/STATE/ZIP �/�—A1C t/ ( •�Y � CONTRACTOR I!9 1A V ,` PHONE ` CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR/CONSULTANT PHONE SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP LICENSE ❑ C-57 1 C-61 ❑ D-09 1 Other NUMBER EXPIRATION DATE BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) INTENDED USE Domestic/Private Irrigation/Agricultural _- 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 C 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 =i Pump Repair ❑ Raise Well Casing WELL CONSTR TION Drilling Method ❑ Mud Rotary C Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom D Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Sched D Steel I i Plastic J Stainless Steel -1 Other Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) 1 Sand Cement sack mix/7 gal water Bentonite(20%solids) Ei Other Grout Placement Method ❑ Pumped D Free Fall ❑ Other -] Retardant/Accelerator(name) PEDESTAL Installed By AZriller ❑ Pump Contractor Other_ Concrete Pedestal[]Dimensions:Width tt Length ft Thick in F' Christy Box ❑ Stove Pipe PUMP Submersible❑ Turbine D 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 CO NSATION LAWS. MI 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 SIGNED TITLE (J m_r DATE Nq DEPARTMENT SE ONLY ENT AApplication Accepted By0) Date Area q Employee ID#V0 0^0A Grout Inspection B Date SPECIAL Well Permit Pump Inspection By 0-"'L Date G WAIVER Received Soil Boring I ection By Date Constructe Well Depth ft COMMENTS �f I PE SC Received Check#/ Amount Da Permit/ Invoice# Well ID# Codes Info B as Remitted Service Request# EHD 43-06 6/11/2019 WELL/PUMP PERMIT