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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 J�/,/ www.s ov.or /ehd EXPIRES 1 YEAR FROM GDATE ISSUED JOB ADDRESS 7/ 14 b �� ,, 7— �[�(/�/ �� / CITY/ZIP G.u��/>2�/�>�S �il /✓�Z 7 m v/ /0d' APN U I C� I t� S( D CROSS STREET / SG�7 PARCEL SIZE LAND USE APPLICATION# o OWNER NAME �/L4V['i' 26&V'/l��C �PHONE q XI,'��WU"(J//00, N OWNER ADDRESS y� CITY/STATE/ZIP G/LG�iiyr�� 9�ZZ 7 CONTRACTOR J/, ! / PHONE AV? 772/-z/7�5 7 CONTRACTOR ADDRESS � /�' ��%G i((/j�!/1`f7 /�$ CITY/STATE/ZIP A� �/7stS SUBCONTRACTOR/CONSULTANT PHONE SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP >,, LICENSE � C-57 C-61 ❑ D-09 L Other NUMBER �!/ 07 ExPIRATION DATE BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE ❑ Domestic/Private )4 Irrigation/Agricultural ❑ Industrial 11 Water Quality Monitoring I1 Soil Sampling/Characterization 0 Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ANew Well ❑ Replacement Well i Well Alteration/Modification 1 Other I 1 Monitoring Well(s) #of wells I-1 Soil Boring(s) #of borings ❑ Geotechnical #of borings Ll Out-Of-Service Well ❑ Out-Of-Service Well Renewal ',j Cross-Connection Repair New Pump ❑ Pump Replacement ❑ Purnp Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method k Mud Rotary ❑ Air Rotary F1 Auger ❑��C/ate/ble TL_ ❑ Push Point I Other Proposed Well Depth 3&0, Excavation JlJ -/ its c7fameter ❑ Open Bottom kt! Gravel Pack/Gravel Sized in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diam4ter in Thickness/Gauge/ASTM Sched S 5 Z/ ❑ Steel XPlastic ❑ Stainless Steel ❑ Other Grout Seal Depth 5 ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ,Sand Cement sack mix/7 gal water I I Bentonite(20%solids) :1 Other Grout Placement Method jd Pumped ❑ Free Fall LI Other ❑ Retardant/Accelerator(name) EN PEDESTAL Installed By ❑ Driller !I Pump Contractor K Other RE LI Concrete Pedestal[I Dimensions:Width ft Length ft Thick in CI Christy Box ❑ Stove Pipe PUMP Submersible❑ Turbine IJ Other HP LS Pump Set ft Standing Water Level I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCOId8A1QIIjj,SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUII1f3PL!/I �j CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMF1tMftTR&#N. NT WORKERS COMPENSATION LAWS. MINIMUM 48 R ADV CEN ICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209)953-7697 SIGNED TITLE Cj^'� ��L'rt�i^.L DATE 7 3 r 1 t � i 01 J' dff R �, ,. �- .. i_ fir'.. �., X LFj •'....�� # .. r � DEPARTMENT UPE_ O LY Application Accepted By Date /13 Area Employee ID# Grout Inspection By Date —�p—�?~ SPECIAL Well Permit Pump Inspection By �rG c,acs �QC�l2�'� Qw L Date WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS I i e, Or ?" rc oma a C D r �- eceivedc #/ Amount ate Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Re uest# q IR0 44V1 &5.1 a) IS O 0 5 t+,:;NC' 0 5't 1 6-2 24�49.2014 POO 4-0-9 30 EHD43-06 6/11/2019 WELL/PUMP PERMIT