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WELLIPUMP 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 GEXPIRES 'I YEAR FROM DATE ISSUED JOB ADDRESS �� CITY/ZIP IF /zyw�APN (SF� � old ` CROSS STREET PARCEL SIZE ��`� LAND USE APPLICATION# o OWNER NAME ,�—C�/'f� PHONE -�j s� PM m OWNER ADDRESS _ CITYISTATE/ZIP CONTRACTOR ,U�/ i� -� J PHONE ` C CONTRACTOR ADDRESS lZ�fil��-Gds �� CITY/STATE/ZIP 57�— _�j2_ �5 SUBCONTRACTOR/CONSULTANT PHONE SUBCONTRACTORICONSULTANT ADDRESS CITYISTArE/ZIPP ^� /_/j LICENSE A1C-57 )VC-61 ❑ D-09 ❑ Other NUMBER O /� EXPIRATION DATE L BILLING PARTY: ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT —"7 DOMESTIC WELL SAMPLING:D General Mineral/Coliform Bacteria(4391) D Dibromochloropropane(4392)D Arsenic(4393) INTENDED USE omestic/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 D Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump )tPump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION 11 Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger D 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 Weil Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ 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 DDimensions:Width ft Length ft Thick in ❑ Christy Box D Stove Pipe PUMP ubmersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level 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. IVIINI � CE NOTICE REQUIRED FO�PECTIONS -PLEASE CALL (2U9) 9.� �� SIGNED I TITLE � P2 DATE r .rsa' It Rh T PA ralm A JAUI IR N E T N DEP RTMENT USE ONLY Application Accepted By Date Z Area 2 5� Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By jf,A, ^S CO C h 1 Date [ (3Q?V ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE Sc Received Check# Amount Permit) Codes Info B ash Remitted Date Service Request# Invoice# Well ID# EHD 43-06 6/11/2019 WELL/PUMP PERMIT