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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 CITY/ZIP m ~ t7 D LAND USE APPLICATION# A CROSS STREET AP PARCEL SIZE fv OWNER NAME /� n PHON/Ec nn a/.�1 /^/v//, rn OWNER ADDRESS l5(c0 CITY/STATE/ZIP C;f 1�l� 6 � l 211//` / CONTRACTOR PHONE-W//�� 1 3c)c)_1/Oyu CONTRACTOR ADDRESS CITY/STATE/ZIPS (J—ry(//Q( lJ SUBCONTRACTOR/CONSULTANT PHONE�Q�/ —54/—j 36 SUBCONTRACTOR/CONSUX LTANT ADDRESS CITY/STATE/ZIP�� `� " (!J✓✓� LICENSE C-57 C-61 ❑ D-09 ❑ Other NUMBEREXPIRATION DATEBILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE Domestic/Private fj 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 Fl Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings Geotechnical #of borings i7 Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair New Pump 11 Pump Replacement L] Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method 6Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth 330 ft Excavation 11� in diameter CI Open Bottom Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter—to— in Thickness/Gauge/ASTM Sched 900 1.i Steel Xic Plastic ❑ Stainless Steel Other Grout Seal Depth 100 ft Ll Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ,.Bentonite(20%solids) ❑ Other Grout Placement Method jr Pumped ❑ Free Fall ❑ Other I Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller 0 Pump Contractor ❑ Other ❑ Concrete Pedestal L]Dimensions:Width ft Length ft Thick in 1 Christy Box ❑ Stove Pipe PUMP Submersible❑ Turbine ❑ Other HP Pump Set Oo ft Standing Water Level /S'O{' 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. MINI U 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTI S -PLEASE CALL(209) 953-7697e� SIGNED / — TITLE DATE E C (i D pA E ARTMENT U E ONLY Application Accepted ByDam Area_ Employee ID#r 11 t" Grout Inspection By Date 21 u L(' ��11SPECIAL Well Permit Pump Inspection By Sw vr'%a xAMw�ti Date (2 if 1v7Z WAIVER Received Soil Boring Inspection By Date Constructed Well Depth 1 1 ft COMMENTS k � PE SC Received heck Amount Date Permit/ Invoice# Well ID# C d s Irjfo Bv A Cash Remitted Service Re uest# 0 4) �1 ?J C EHD 43-06 6/11/2019 WELL/PUMP PERMIT