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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 on www.sjgov.org/ehd EXPIRES 1 YR FROM DATE ISSUED JOS ADDRESS 2 �^ rtj CITY/Z !15m CROSS STREET u r� >U—0 � I'3' D _%PN p� ARCEL SIZE AND USE APPLICATION#) J� U � P �1 L�S ` o PHONE �O J — loo 20 m OWNER NAME / Q / �/ f�J� /, y OWNER ADDRESS `2 i LP(f l �`•1 l� / CITY/S /LIF4 to/• q�l �� J L) �J CONTRACTOR e � V 4 J CJS Jd,V N [504 M CONTRACTOR ADDRESS ! U l CITY/ TATE I "" �`�I ✓ �v SUBCONTRACTOR/CONSULTANT I \/f PHONE 1WIA SUBCONTRACTOR/CONSULTA T ADDRESS / I CITY/STATE/ZIP I V LICENSE _ C-57 Y C-61 _ D-09 LI Other 021 NUMBERO EXPIRATION DATE �/( t/✓ BILLING PARTY: OWNER /CONTRACTOR _i SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) = Dibromochloropropane (4392)❑ Arsenic(4393) INTENDED USE Domestic/Private L 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 a Replacement Well L I Well Alteration/Modification ._I Other - Monitoring Well(s) #of wells n Soil Boring(s) #of borings - Geotechnical #of borings Out-Of-ServicYePump Well _I Out-Of-Service Well Renewal U Cross-Connection Repair - New Pum Relacement I Pum Re air L Raise Well Casing WELL CONSTRUCTION IF Drilling Method _. Mud Rotary !-I Air Rotary 11 Auger _ Cable Tool Push Point Other Proposed Well Depth ft Excavation in diameter 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 _ Plastic _ Stainless Steel L Other Grout Seal Depth ft 11 Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water r Bentonite(20%solids) :1 Other v 1 Grout Placement Method - Pumped A Free Fall 1-1 Other n Retardant/Accelerator(name) PEDESTAL Installed By - Driller ❑ Pump Contractor E Other ncrete Pedestal LlDimensions:Width ft Length ft Thick j in _ Christy Box a Stove Pipe iPUMP Submersible- Turbine n Other HP Pump Set `_'E ft Standing Water Levelft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDIN NCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTT' c 1TH Ti•IE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT i AMvi IN CC riPLiANCE WITH ALL WORKERS COMPE S T N LAWS. MINIMU OUR VANCE NOTICE REQUIRED FOIRJNSPECTIONNSS -�PLEASE CALL (20t) 9y3-7P97 SIGNED TITLE S / / �"" DATE (� c IV .•i A 4rO A UI �EPg FFRa Tq L 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 'rTnPE�llr J DEPARTMENT USE ONLY Application Accepted By Date / ovJ Area L� —1 -/ Employee ID# Sx Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By '�lf,�•�S a (9n n L Ids` Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS \ Oyu Go (1b 1 /. ;h PE SC Received Ch Amount Date Permit/ Invoice# Well ID# Codes Info Cash Remitted aervice RAO, e # 93Fi 0s o �3d4 77 EHD 43-06 6/11/2019 WELL/PUMP PERMIT