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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.Ngov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS y CITY/ZIP V��J m �! �� D CROSS STREET APN �I PARCEL SIZE LAND USE APPLICATION# o OWNER NAME7E6 PHONE 11��JJ�•��] l yf VSX OWNER ADDRESS (bngCITY/STATE/ZIPaMkfM X7 CONTRACTOR II��(( ^�n y�'-'Q� 1 /1� PHONE CONTRACTOR ADDRESSO`0o `�� 1 66k — Crn�l CITY/STATE/ZIP �w 1 SUBCONTRACTOR/CONSULTANT N 4 4 04 PHON 44 SUBCONTRACTOR/CONSULTANT ADDRESS C 4TY/,$TATE/ZIP LICENSE -57 CI C-61 L, D-09 n Other NUMBER*Wlp ExPIRATION DATE BILLING P RTI: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE XDomestic/Private ❑ Irrigation/Agricultural =1 Industrial -_1 Water Quality Monitoring �] Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK 1 New Well G Replacement Well ❑ Well Alteration/Modification ❑ Other Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service ell Out-Of-Service Well Renewal ❑ Cross-Connection Repair I i New Pump 0('Pump Replacement ❑ Pump Repair CI Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point -1 Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 1 Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched I I Steel LlPlastic I 1 Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water J Bentonite(20%solids) _- Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By n Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal F1 Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersible 1-i Turbine 11 Other HP I 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 WORKE OMPENSATION LAWS. MI U 4R DV NCE NOTICE REQUIRED F INSP NS -PLEASE CALL(209)95'3-769 67 SIGNED TITL DATE ti Ek Ir N p k TL N E P R T M ENT USE O LY 7 Application Accepted By Date Area ` I Employee ID# suhkiee1 Grout Inspection By Date SPECIAL Well Permit Pump Inspection By Date fl WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS ZI �'L� V 1 N L O C ' - �J PE SC Received he Amount Date Permit/ Invoice# Well ID# Codes Info Bv Cash Remitted Service Request# �I381 eso Off' 7 7 0 EHD 43-06 6/11/2019 WELL/PUMP PERMIT