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11(,B �6Y u Sh arrd k/cd WELL/PUMP PERMIT SAp]_Innniuy COUNTY ENVIRONM6 T HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 NON-REFUNDABLE PER..... 3L V %yww.sjgov.org/ehd EXPIR I YEAR .ROM DATE ISSUED q JOB ADDRESS ' l Iq/\ l ,( IT�Y/ZIP I V 0 11 D CROSS STREET (� �A7PN /7 6Z PARCEL SIZE LANA USE APPLICATION CROSS OWNER NAME �V ► J CSS QS n� 14( PH(0✓ONEZ L `I Com/ m OWNER ADDRESS CITY/STATEIZIP -�pE5J�dv v/��o� ivtv\ CONTRACTOR `T � o ( PHO CONTRACTOR ADD �`JJ9 y/ Y �� ✓ �� SUBCONTRACTOR/CONSULTANT [ HONE SUBCONTRACTOR/CONSULTANT ADDRESS 7 f CITY/STATEIZIP I LICENSE _ C-57 C-61 _ D-09 U Other NUMBER{ (PL(0 1) EXPIRATION DATE V, BILLING PARTY: OWNER n CONTRACTOR 1 SUBCONTRACTORICONSULTANT DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria (4391)- Dibromochloropropane(4392)❑Arsenic(4393) � INTENDED USE Domestic/Private U Irrigation/Agricultural _ Industrial _ Water Quality Monitoring _ Soil Sampling/Characterization 1' _ Public Water System 1 If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK _ New Well U Replacement Well U Well Alteration/Modification J Other - Monitoring Well(s) #of wells n Soil Boring(s) #of borings , - Geotechnical #of borings _ Out-Of-Service Well U Out-Of-Service Well Renewal U Cross-Connection Repair - New PUmR ,❑^ Pum Replacement um Repair / E Raise Well Casing WELL CONSTRUCTION L Vl Id(A m.n �� `/( rr Drilling Method _ Mud Rotary U Air Rotary U Auger _ Cable Tool L Push Point _ Other Proposed Well Depth ft Excavation in diameter _I Open Bottom L Gravel Pack/Gravel Size in diameter _ Conductor Casing_ in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Sched J Steel U Plastic - Stainless Steel U Other t- Grout Seal Depth ft n Neat Cement(94/b bag/5-10 gal water) n Sand Cement sack mix/7 gal water - Bentonite(20%solids) ❑ Other Grout Placement Method - Pumped n Free Fall n Other n Retardant/Accelerator(name) PEDESTAL Installed By - Driller ❑ Pump Contractor C Other - _Q _ ConcretePedestal UDimensions:Width ft Length ft Thick in _ Christy Box U Stove Pipe PUMP A Submersible- Turbine n Other HP Pump Set_ UI U ft Standing Water Level f �J 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 S ION LAWS. MINIM 8 HOUFyaDVANCE NOTICE REQUIRED FO IINSP�/E/C��TypIONnS/� PLEASE CALL (209) 95`-76 7 SIGNED TITLE " Ell( ter 1 Ii24 a DATE � c lea JUAl�- vv S O � M U A T I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I DEPARTMENT USE ONLY �G Application Accepted By T,p1�U Date dS 0107 a Area 5 Employee ID# SK Grout Inspection By f Date �7 ❑ SPECIAL Well Permit Pump Inspection By t `o nG+S to �_QQ�(C.�e, ` L Date 1 9(Zp D ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS Well IS b-- _-,ke ied bp+wePn DcIrcpl5_ de11 Ylmciy,�t be stili+leyl iFo�� e,(mWted P61f6 1S, PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info By Remitted Service Request# N38c� asooo EHD 43-06 6/11/2019 WELL/PUMP PERMIT