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'LVED�I WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 NON-REFUNDABLE PERMIT / www.s Ov.or /ehd EXPIRES 1 rYEAR FROM /M1D/ATE ISSUED JOB ADDRESS !4t& W, In (L 4 re—A CITY/ZIP vk " ��—►(i'�1 S �� I m 2 I . D CROSS STREET ee l� APNI"t 7 ZLf()U PARCEL SIZE LAND USE APPLICATION# ►^� f� A OWNER NAME Y_L 1 P—u q G'Il%0 PHONE "I, EdJ�� ryy N OWNER ADDRESS (Jl Y.\-e, CIN/STATE/ZIP CONTRACTOR 1(,�I F�YJ i b Y I l( �I r 1% PHONE `,��/-� CONTRACTOR ADDRESS V IZJ^ 14L4 f�`�1 lY CITY/STATE/ZIP I 6R6(A SUBCONTRACTOR/CONSULTANT PHONE SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP 11�� LICENSE ),C-57 j C-61 ❑ D-09 ❑ Other NUMBER "� EXPIRATION DATE I V BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial = Water Quality Monitoring -1 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 F-1MonitoringWell(s) #of wells [I Soil Boring(s) #of borings ❑ Geotechnical #of borings E Out-Of-Service Well ❑ Out-Of-Service Well Renewal Cl Cross-Connection Repair New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTI Drilling Method C Mud Rotary -i Air Rotary ❑ Auger C Cable Tool Push Point .1 Other Proposed Well Depth ft Excavation - in diameter 1_I Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth It Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel ❑ Plastic ❑ Stainless Steel 11 Other Grout Seal Depth ft F! Neat Cement(94 lb bag/5-10 gal water) C': Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) Cl Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other 1-1 Retardant/Accelerator(name) PEDESTAL Installed By YDriiier ❑ Pump Contractorl El Other ❑ Concrete Pedestal[]Dimensions:Widthft 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. MINIMUM 48 OU DVE NOTICE REQUIRED FOR INSP1 CTII/O/NS -PLEASE CALL(209) 9153-7697 SIGNED TITLE ` "`'Y DATE v 2—Cl I G� IN L H T D P T E T D ARTMEN /T SE ONLY ,+ Application Accepted By Date 6 Area / Employee ID# Grout Inspection By 1 ' Date SPECIAL Well Permit Pump Inspection By, /�1�,c1Ccn Date Int WAIVER Received Soil Boring I snpec/tion By \Ij Date Constructed Well Depth ft COMMENTS PE Sc Received Check#/ Amount ate Permit/ Invoice# Well ID# Codes Info Cash Remitted Service Request# EHD 43-06 6/11/2019 WELL/PUMP PERMIT