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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)466-3420 ` NON-REFUNDABLE PERMIT Qwww.sjgov.org/ehd f�EXPIIRR�E'(S 11 YEAR FROM DATE ISSUED ' JOB ADDRESS C 1,�, ISR ` CITY/ZIP �L`+1Vv`�1- ' ' 1S L CROSSSTREET U WU,kb� u' A`P>N f`` R - �W_ IW PARCEL SIZE I� rt`LAND USE1/APPPLIC1ATION# ny1`r` A OWNER NAME �r ,�1�/�'` ��`q,�y V �U\71 LOS, c_ ck)�ILLA _ U 1 V 1 y OWNER ADDRESS (o1I(,OA'`ut� IJIA_h /�CLl/l CITY/STATE/ZIP LO ,V C`/ A 1C V 40 ALA?j CONTRACTOR V 4 U) 'y'r it nom'\ PHO`N&M 1 "1(/y0i r 1-70y CONTRACTOR ADDRESS `\�/1�,`r�\v��per` CITY/STATE/ZIP C)CA`�f ' `1 SV N� SUBCONTRACTOR/CONSULTANT Wo,%k "u�Cj�� ASbOC�UW-S ,,tPHIONE (q(06 1Z-,{.l Lt3f44. SUBCONTRACTOR/CONSULTANT ADDRESS �W ln�^' t U'1 %`y� CI^TY//STATT/EE/ZItP1 W`a� VGUG(UV(taell X'1.0 /C ,I 0 I LICENSE S/C-57 ❑G61 ❑D-09 ❑Other NUMBER ILO"104 EXPIRATION DATE LA (30/1022 BILLING PARTY: ❑OWNER ❑CONTRACTOR D SUBCONTRACTOR/CONSULTANT DoMEsTlc WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)D Di bromochloropropane(4392)❑Arsenic(4393) INTENDED USE D Domestic/Private ❑Inigation/Agricultural ❑Industrial D Water Quality Monitoring Soil Sampling/Characterization D Public Water System If different from Owner. Water System Name Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well -'Nell Alteration/Modification ❑Other ❑Monitoring Well(s) #of wells oil Boring(s) #of borings pf Geotechnical Li #of borings , ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair ❑New Pump ❑Pump Replacement D Pump Repair D Raise Well Casing WELL CONSTRUCTION Drilling Method ❑Mud Rotary 0 Air Rotary ❑Auger ❑dCable Tool ❑Push Point ❑ Other Proposed Well Depth 15 ft Excavation (0' 0 in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth It Well Casing Diameter_in Thickness/Gauge/ASTM Sched 0 Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth 1 S It @(Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water D Bentonite(20%solids) 0 Other Grout Placement Method ❑Pumped if Free Fall L"Other A^R"t O Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other ❑Concrete Pedestal❑Dimensions:Width ft Length It Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersibleo Turbine 0 Other HP Pump Set It Standing Water Level It 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. MIN IMU -48 HO R ADVANCE NOTICE REQUIRED FOR INSPECTIONS ((N�SP TION�Sjl�-pPLEASE CALL(209)963-7697' SIGNED TITLE \Jt �'v1t�"D_� DATE 11 I �lJ 7p� �® kk Air aim 9 ?0?0 f) LIN ENT coorY At TMENT DEPARTMENT SE ONLY �C, Application Accepted By Date i l Area / l Employee ID# JA Grout Inspection By Date 2 W 04 SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Ins ection B Date Constructed Well Depth ft COMMENTSppnLAb '1C PE SC Received C Amount Date Permit/ Invoice# Well ID# Codes Info B i s .Remitted Service Request# SO a EHD 43-06 6/11/2019 WELL/PUMP PERMIT