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WELLIPUMP PERII F SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZEL-ON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 NON-REFUNDABLE PERMIT I www.sjgov.org/ehd �Ely,PIRES 1 YEAR FR DATEISSUED JOB ADDRESS V CITY/ZIP �I r 1 �f/ m _ m b a 6 n CROSS STREET P;)I C APN dd33 I(�OO6 PARCEL SIZE LAND USE APPLICATION# m 1 Vril U rl 2�rY-t XN E U 1 OWNER NAME — OWNER ADDRESS .21o, I&jw low M CITY/S A IP k L CONTRACTOR " e' ! vl r , 9_� Ll PHONE - ~~v r 1 (Jy t4 " 1� Q CONTRACTOR ADDRESS ✓" i�'/ CITY/S"11P1 1 SUBCONTRACTOR/CONSULTANT IVf y P.�nHONE SUBCONTRACTOR/CONSULTANT ADDRESS f" CITY/STATE/ZIP L✓I f LICENSE _ C-57 XC-61 _ D-09 _ Other 1921 NUMBER D-7(p"'(+"' EXPIRATION D _1 Z V v BILLING PARTY: - OWNER '.CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: D General Ivlineralf0oliforrn Bacteria (4391) _ Dibrofncchloropropane (4392) 'D Arsenic(4393) INTENDED USE omestic/Private L; Irrigation/Agricultural - Industrial _ Water Quality Monitoring _ Soil Sampling/Characterization _ Public Water System If different from Owner: Water System Name Contact Name or Ph:�IA TYPE OF WORK New Well a Replacement Well U Well Alteration/Modification _ Other � o9s Monitoring Wells) #of wells -jSoilBoringf/s) f borings - Geotechnical Out-Of-Servic ell Out-Of-Service Well Renewal Cross-Connection RepAUG q �O (� New Pump Pump Replacement ❑ Pump Repair - Raise Well Casing _[ �___ WELL CONSTRUCTION EN C)AQU/N Z (Drilling Method _ Mud Rotary a Air Rotary a Auger ' _ Cable Tool _- Push Point _ Other NEALT ONMECO LN Proposed Well Depth_—ft Excavation in diameter _j Open Bottom Gravel PackiGravel Size in diameter �1 _ Conductor Casinin diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched j Steel Plastic Stainless Steel Li Other Grout Seal Depth ft n Neat Cement(94 Ib bag/5-10 gal water) 7, Sand Cement sack mix/7 gal water W - Bentonite(20%solids) D Other Grout Placement Method ` Pumped � Free Fall n Other r� Retardant/Accelerator(name)— PEDESTAL Installed By - Driller D Pump Contractor E Other _ Concrete Pedestal ijDimensions:Width ft Len th ft Thick in _ ChristWBox U Stove Pipe PUMP Submersible- Turbine F1 Other HP Pump Set_ ft Standing Water Lev ft I HEREBY CERTIFY HAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY RDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND AC VE ,)KITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPE fA,.ON LAWS. MINIM r 4 HOUR ADVANCE iNOTiCE REQU11RED FOR NSPECTION/S/'-PLEASE CALL (243) 9P-7691Z,6 7 SIGNED TITLE �/` �� / l lA y) DATE Z .y f f — I I I I I I I I I I I I L-1 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 �� 1�' Date /'a --wo Area 3mGd eCG Employee ID# FR Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date kkktOk-WW 1-1 WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS jc(d QfjcjIJ4ft C.,f o56( PE Sc Received C Amount Date Permit/ Invoice# Well ID# Codes Info B ash Remitted I Service R q est L139 1 050 $77 X EHD43-06 6/11/2019 WELL/PUMP PERMIT