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A C/(ap i WELL/PUMP PERMIT SAN JOAQUIN COUNTYENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205.6232 (209)468-3420 NON-REFUNDABLE PERMIT 2 y� WWW.S ov.of lehd EX/VPII�pRES 1(//JYEAR FROM DATE ISSUED Cn JOB ADDRESS Y V -f ✓ 6" r_h �� CITY/ZIP +� q��® D CROSS STREET L(l Ill it YS /d APN 3 101 0,F000 PARCELSIiE.0,0 LAND USE APPLICATION# A Arrhm II /� /� �y/� J a ''/) m OWNER NAME • ✓ 0 r` )I / PHON��"� � OWNER ADDRESS d d W'� �" I ►✓ CITY/STATEIZIP � / J / d� CONTRACTOR J �' V� v HONE ✓�/� t CONTRACTOR ADDRESS St/ y 9 V __ �JTYSTA 1 �� SUBCONTRACTORICONSULTANT'VIA PHONE SUBCONTRACTOR/CONSULTANTADDRESS N I/ �^(1CITY/STA�TTEIZIIP v 4 LICENSE _ C-57 C-61 _ D-09 U Other a NUMBEK '� EXPIRATION DATE ' 3 BILLING PARTY: -OWNER 1 CONTRACTOR 1 SUBCONTRACTOR/CONSULTANT may' DOMESTIC WELL SAMPLING:D General Mineral/Coliform Bacteria(4391)= Dibromochloropropane(4392)❑Arsenic(4393) ) INTENDED USE Domestic/Private U Irrigation/A4ricultural _ 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 U Replacement Well U Well Alteration/Modification _ Other - Monitoring Weil(s) #of wells n Soil Boring(s) #of borings -.Geotechnical ,t of bo ngs _ Out-Of-Serviell U Out-Of-Service Well Renewal U Cross-Connection Repair = New Pum C3?Pump Replacement ❑-Pump Repair C Raise Well Casing WELL CONSTRUCTION Drilling Method _ Mud Rotary U Air Rotary U Auger _ Cable Tool L Push Point _ Other Proposed Well Depth ft Excavation in diameter J Open Bottom L Gravel Pack/Gravel Size in diameter �f _ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Sched J Steel U Plastic _ Stainless Steel U Other Grout Seal Depth ft n Neat Cement(94/b bag/5-10 gal water) n Sand Cement sack mlx/7 gal water = Bentonite(20%solids) U Other Grout Placement Method - Pumped n Free Fall n Other n Retardant I Accelerator(name) PEDESTAL Installed By = Driller ❑ Pump Contractor C Other _ Concrete Pedestal UDimensions:Width ft Len th ft Thick in _ Christy Box U Stove Pipe PUMP Submersible- Turbine n Other HP Pump Set ft Standing Water Level ft `� w 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 a� WORKERS COMPENSATION LA %% MINIMUM 48 HOU DVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL.(209)953- 697 1 -1 12j SIGNED `"--' TITLE (•/ �a ➢ DATE. 10 tA Ll I r V-40 q RVg 0 P r4 >' Nr 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 I I I I DEPARTMENT USE ONLY Application Accepted By L—�Z' Date11 a10R0 Area VCfq Employee ID#_F Grout Inspection By Date p ❑ SPECIAL Well Permit Pump Inspection By 1 c9 ;v ( � Date -I �,t7 ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE Sc Received Check# Amount Date Permit/ Invoice# Well ID# Codes Info B as Remitted Service Re uest# 4391 050 30 k 32 $77 1-14-10 EHD 43-06 6/11/2019 WELL/PUMP PERMIT