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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 PIRES 1 YEAR FROM DATE ISSUED y Ln I�3 r��-(/l JOB ADDRESS koollCITY/ZIP Dr'it r y CROSS STREET amax ed APN O 17'9 CI`7 7 PARCEL SIZE L LAND USE APPLICATION## o OWNER NAME ka Mm i fi I rzro a PHONQQ20 � n" C�/U CJ V 9 N OWNER ADDRESS CQV CITY/STATE/ZIP CONTRACTOR PHONE ��jyy)//Q��-/J► �( CONTRACTOR ADDRESS / Ayid CITY/STATE/ZIP SUBCONTRACTOR/CONSULTANT PHONE SUBCONTRACTOR/CONSULTANT ADDRESS Y/STATE/ZIP LICENSEC-57 ❑ C-61 ❑ D-09 ❑ Other NUMBE EXPIRATION DATE BILLING PA TY: ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT DOMESTIC WELLSAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ublic 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-ServiceW II ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump 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 ❑ 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 ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ 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 ❑ 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. MIVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953 76 7 SIGNED- /L� TITLE��L DATE r 7 Z. V / DEPARTMENT USE ONLY ?'Altt 7-Y Application Accepted By Date M 7 Do+ D Area Employee ID# Grout Inspection By Date y El SPECIAL Well Permit Pump Inspection By �f��W��l G�. Date 6(5�� ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Che Amount Date Permit/ Invoice# Well ID# Codes Info BV Cash Remitted Service Request# N3 a�a Da- 7 0•1-210 EHD 43-06 6/11/2019 WELL/PUMP PERMIT