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WELL/PUMP 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 EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS �OI +• tiyir/V �0, �,�r��p�r�� CIrY/ZIP froci T9�V I S'LyS m QQ R 0-1w p"0 n--------- D CROSS STREET I ACA Q.Q _APN /r��nOO'O TO'"0 PARCEL SIZE/�g4LAND USE APPLICATION# a OWNER NAMESq/�GJ{Et /, PHONE N OWNER ADDRESS 7*z0�_) POA*L-o PA CITY/STATE/ZIP L✓b!f Hju j.X C/+ q J71197 CONTRACTOR V W y��.L�� / PHONE/�O=, CONTRACTOR ADDRESS A/3 7 ?-�4CKKjgN p4.. CITY/STATE/ZIP 441'ry,rrel+ Z S6 3Z SUBCONTRACTOR OSULTAN /�'�� Q(ti^k{///r, r4JSOGLq�t�rJ PHONE1!/`�l?Z-/y1y' SUBCONTRACTOR/CONSULTANT ADDRESS'FOTO t6/A,fj 144+t- 'jIyrP CITY/STATE / Z IP W&T S*(aA{(►'10 C4 `!)6 91 LICENSE XC-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 7 2� `�/ EXPIRATION DATE Y O 2s BILLING PARTY: ❑OWNER ❑CONTRACTORON SUBCONTRACTOR/ SULTANT DOMESTIC WELL SAMPLING:F.i General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)n Arsenic(4393) INTENDED USE D Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ 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 ❑ Well Alteration/Modification D Other ❑ Monitoring Well(s) #of wells �II Boring(s) #of boringsGeotechnical l0 #of borings ❑ Out-Of-Service Well 'D Out-Of-Service Well Renewal ❑ Cross-Cdnnection Repair ❑ New Pump ❑ Pump Replacement ❑ Purnp Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary P(Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth 2,0 ft Excavation —b 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 D Other Grout Seal Depth ft ;Idgeat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall X10ther � � 4 D Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other D Concrete Pedestal❑Dimensions:Width ft Length_ ft Thick in ❑ Christy Box D 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. MI UM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209)953-7697 SIGNED TITLE V -14VC-Iri DATE ZtO O 4 D . P RTM ENT USE ONLY ( Application Accepted ByAIL Date �� /ZO/ZO Area 6�Y A Employee I D# �C'_r'L•o'._ Grout Inspection By Date D SPECIAL Well Permit Pump Inspection By Date 11 rr ❑ WAIVER. Received Soil Boring Inspection By - Date {1 Constructed Well Depth ft COMMENTS PE S,C Received kCheckq Amount Date Permit/ Invoice# Well ID# Codes Info B Remitted Service Re uest# a EHD43-06 6/11/2019 WELL/PUMP PERMIT