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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 u vc u t � X5.215 m JOB ADDRESS CITY/T10 � m l � D CROSS STREET /War O��- APN '��0j PARCEL s J3 LAND SE APPLICATION# A G YU e �S J QZ-E I , �j1.- (SCJ�7 ? y OWNER NAME � �) IA� ),,/ � � ��f� �( y OWNER ADDRESS/V`71p�/ '`� r NO✓Y � �C" - CITY/STATE/ZIP � • ' � / CJ I 1 / S�/� j ✓�I! �� _ e P ONE 1 �0,�. (CONTRACTOR ]�G `� ��J QN kV CONTRACTOR ADDRESS 5" `r / �� CITY/ $TAT "' ✓ V c SUBCONTRACTORICONSULTAN 1 ~ PN,E SUBCONTRACTOR/CONSULTANT ADDRESS / CITY/STATEIZIP LICENSE _ C-57 VLj C-61 _ D-09 Othe 21 NUMBER -7(P(9 to EXPIRATION DATE" BILLING PARTY: OWNER CONTRACTOR 1 SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391) = Dibromochloropropane(4392) Arsenic(4393) Y 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 l TYPE OF WORK _ New Well U Replacement Well U Well Alteration/Modification _ Other Monitoring Well(s) #of wells n Soil Boring #of borings s) - Geotechnical #of borings _ Out-Of-Service Well . LI Out-Of-Service Well Renewal L,, Cross-Connection Repair C New Pump ❑ Pump Replacement ❑ Pump Repair = Raise Well Casing WELL CONSTRUCTION ,Drilling Method _ Mud Rotary LI Air Rotary Auger _ Cable Tool L_ Push Point _ Other o Proposed Well Depth ft Excavation in diameter J Open Bottom i Gravel Pack/Gravel Size in diameter _ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched J Steel D Plastic _ Stainless Steel u Other Grout Seal Depth ft n Neat Cement(94 Ib bag/5-10 gal water) r Sand Cement sack mixl7 gal water Bentonite(20%solids) D Other Grout Placement Method - Pumped n Free Fall n Other Retardant/Accelerator(name) PEDEN& Installed By = Driller XPump Contractor E Other _ Concrete Pedestal UDimensions:Width ft Len th ft Thick in _ Christy Box U Stove Pipe PUMP Submersible- Turbine n 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 WTIVEWITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COM NS ON LAWS. MINI HOUR ADVANCE NOTICE REQUIRED F INSPECTIONS -PLEASE CALL (209 76 7 SIGNED TITLE via a 1 / �G� DATE l �+ A 11 Lo 71 ISA JAUI C U 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 B Date Ig doao pp p y Area _ Employee ID# Fie Grout Inspection By Date E SPECIAL Well Permit Pump Inspection By Lo �•=e �-�.•�. Date \'�tti91� 1-' WAIVER Received Soil Boring Inspection By _ Date Constructed Well Depth ft COMMENTS 18&11 DefMr4- VAIfj0qOqq!7 PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info yj ash Remitted Service Re uest# 80 05-1 EHD 43-06 6/11/2019 WELL/PUMP PERMIT