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.A WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 NON-REFUNDABLE PERMITwww.sjgov.org/ehd cL.EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 13 C)o 4( I'l'l VII CrrY21P c��Ti7n [ / m CROSS STREET I y�{� APN ��j1h )3 J 0 2 PARCEL SIZE s7 v LAND USE APPLICATION# v OWNER NAME C "}J C k�J/� I/I S')r I t m pp 5O�/Y PHONE r(Aii OWNER ADDRESS ``'� CrrY/STATE/ZIP .y CONTRACTOR C l (J• hn&ArSo r' j Te�'rc.cw1 PHONE ;kcrk) 3 fal-' Ty 1 401 } CONTRACTOR ADDRESS "1 O 1 y CITY/STATE/ZIP W '(A CA Sa tj 0 SUBCONTRACTOR/CONSULTANT PHONE SUBCONTRACTOR/CONSULTANT ADDRESS CrrY/STATE/ZIP ^,,All LICENSE )eC-57C-61 D-09 11 Other NUMBER (eLaGbLj EXPIRATION DATE 5--'3l- pv1 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 X 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 Geotechnical _#of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method 7 Mud Rotary ❑ Air Rotary K Auger Cable Tool Push Point Other Proposed Well Depth (to Excavation in diameter - Open Bottom _ Gravel Pack/Gravel Size in diameter Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Sched Steel ❑ Plastic Stainless Steel Other Grout Seal Depth ( J ft ?t Neat Cement(94/b 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 ;i Pump Contractor Other ❑ Concrete Pedestal❑Dlmenslons:Width ft 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 HOr ADVANCE NOTICE REQUIRED FOR INSPECTIONS -1P—LEASE CALL(209)953-7697 SIGNED / I� v TITLE_ r�1 1�- �CA\��Sc DATE I I I I I 1 qAfr d 0 0;)) U rY DEPARTMENT USE ONLY r Application Accepted By I t /9/�� Area �'� Employee ID# _ 1 Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date WAIVER Received Soil Boring Inspection By Date Z- Constructed Well Depth ft COMMENTS PE SC Received C e Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted ervice Request# �V" 301,22 1 l 1 '1 EHD 43-06 6/11/2019 WELL/PUMP PERMIT