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Wton WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 NON-REFUNDABLE RMI WWW.S Ov.or /ehd PIRES 1 EAR FROM DATE ISSUED /�� jTyn/ 7 �J ur JOB ADDRESS (' l ""1 l �] ]�f CITY/ZIP ` u of; D CROSS STREET 1 Ffb-/l rG1 P AP�/N� / )0+ 1 PARCEL SIZE LAND S/E APPLICATION# U M ! Q0eZ PHU&C, I OWNER NAME OWNER ADDRESS J V I I CITYI TATE/ IP r CONTRACTOR u' �7 1S2t� U s c �17 0 CONTRACTOR ADDRESS J" CITY/STATE IP c 7 ��✓)17 � SUBCONTRACTOR/CONSULTANT l PHONE !7T SUBCONTRACTOR/CONSULTANT ADDRESS � CITY/l1 (STTATOE/ZIP LICENSE _ C-57 C-61 _ D-09 LI Other `—/1 NUMBEri�"1{`� T EXPIRATION DA E )/0 BILLING PARTY: OWNER X CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria(4391) - Dibromochloropropane(4392)❑ Arsenic(4393) INTENDED USE Domestic/Private LI Irrigation/Agricultural _ Industrial _ Water Quality Monitoring _ Soil Sampling/Characterization Public Water System If different from Owner: Water System Name Contact Name or Phone Number r TYPE OF WORK New Well ❑ Replacement Well a Well Alteration/Modification -1 Other f - Monitoring Well(s) #of wells n Soil Boring #of borings s) - Geotechnical c Out-Of-Service Well ❑ Out-Of-Service Well Renewal Li Cross-Connection Repair _ New Pump Pump Replacement- ❑ Pump Repair C Raise Well Casing WELL CONSTRUCTION S4N JD 11 j ?OZ� Drilling Method _ Mud Rotary a Air Rotary U Auger _ Cable Tool i_ Push Point _ Other Proposed Well Depth ft Excavation in diameter -i Open Bottom L Gravel Pack/Gra/t�Q ON CO tii-ameter r-"%Conductor Casing in diameter / Conductor Casing Depth ft qh,T4 �Y Well Casing Diameter in Thickness/Gauge/ASTM Sched � Steel a Plastic _ Stainless Steel a Other FNT Grout Seal Depth ft n Neat Cement(94 lb 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 _ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in _ Christy Box a Stove Pipe PUMP - Submersible- Turbine iii Other HP Pump Seti Zj> 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 CO P SATION LAWS. MINI M 48 OUR ADVANCE NOTICE REQUIRED FO INSPECTIIONNS -PLEASE CALL (209) 953-7697 ( SIGNED TITLE pM Q DATE kill77 r 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 Application Accepted By � Date bohozo Area 7� Employee ID# Dnnn Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By oIJV.��V� t'C,,tt~:c N( -L Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE Sc Received e-ck# Amount Date Permit/ Invoice# Well ID# Codes Info B ash Remitted Service Re uest# u3ei osc) -$7:23� IrJP` 1 EHD 43-06 6/11/2019 WELL/PUMP PERMIT