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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 �cE�XPIRES 1 YEAR FROM DATE ISSUED J � �Lr� ley /�K--� Iu / ��J G� �J: — m JOB ADDRESS `7 [J �f-,/// CITY/ZIP I /l//5f /�` m CROSS STREET JV f C�hiDN hli�A o 9�i y)C)8 PARCEL SIZE LJO LAND USE APPLICATION# 0 m OWNER NAME ��I/ PHONE / OdV/ tcn OWNER ADDRESS <?R� CITY/STATE/ZIP CONTRACTOR /!�O!/�/// (S f�!/^/ r/!/�� PHONE CONTRACTOR ADDRESS _ �! 1>-e CITY/STATE/ZIP SUBCONTRACTOR/CONSULTANT PHONE SUBCONTRACTOR/CONSULTANT ADDRESS P/ACITY/STATE/ZIP LICENSE XC-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE BILLING PARTY:: ❑OWNER [ CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391) ❑ Dibromochloropropane(4392) ❑ Arsenic(4393) INTENDED USE )V Domestic/Private ❑ 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 ❑ 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 ❑ New Pump Oump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool 7 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 [IPlastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal wafer) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal[]Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersible❑ Turbine ❑ 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 COMPENSATION LAWS. 48 ADVANCE NOTICE REQUIRED FOR (INSPECTIONS -PLEASE CALL (209) 9P-707 07 SIGNED TITLE //� DATE IL Wz F Q V/1 o 44T.F.- C1.1 T > Dir Mk T L , c1 l Application Accepted By �� 1�� Date C /G ,70.20 Area ! ��C7 Employee ID# SIS Grout Inspection By " y Date ❑ SPECIAL Well Permit Pump Inspection By Cv'w��,�r, ��,��r 1�w� Date 7/ ZC ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received ck Amount Date Permit/ Invoice# Well ID# Codes Info B sh Remitted Service est# Li� U5� 7 EHD 43-06 6/11/2019 WELL/PUMP PERMIT