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WELL/PUMP PERMIT WV OD41 ) 9 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 'I YEAR FROM DATE ISSUED mo JOB ADDRESS �� CITY/ZIP 5 m �( D CROSS STREET APN D 00 TL'-- ARCEL SIZE LAND USE APPLICATION# O X OWNER NAME PHONE c/14116_ gb5z_�� 7 U) OWNER ADDRESS //��//�� CITY/STATE/ZIP &6_- r /r, A X 6-�( CONTRACTOR goo MCQA�S ,W\�Y S �� PHONE ) !� �(//CJ CONTRACTOR ADDRESS a2/ 2 b ` iV—,-Ax CITY'/STATE/ZIP4SjXAkjnQ" e'4 SUBCONTRACTOR/CONSULTANT PHONE SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP LICENSE A C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE Z/.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 ❑ 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 V,Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 0 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 0 Other Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) 0 Sand Cement sack mix17 gal water 0 Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in 0 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. MIN I��OOM 48 HOUR ADVAN E NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209)v953-76^7� SIGNED TITLE DATE O oGO6 rIL J A UI COUIM J �FR ME NT EPARTMENT US O LY/� Application Accepted By Date �" Area Employee ID# � Grout Inspection By K Date ❑ SPECIAL Well Permit Pump Inspection By CC4�ca'��tt � n� ,� Date Cil�l(lSl�l-C El WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount a Permit/ Invoice# Well ID# Codesy Info Cash Remitted rvice Re uest# 1 0 1A EHD 43-06 6/11/2019 WELL/PUMP PERMIT