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4, - 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 Ll cl ))�� J/��Y1 11^ A rnI �j�/� ��I �t 1vA7 N JOB ADDRESS J V J ` I "' CITY/ZIP - ! m CROSS STREET QyrOn APN a04707_7aa3 Y to a PARCEL SIZEy LAND USE APPLICATION# ,) -�- 1 - 3 �s33 y I OWNER NAME �v z��n� /,�/'� ` �J Q PHONE ` i OWNER ADDRESS ✓ `� lJl I J I b� S V G �✓— CITY/STATE/ZIP� � ��7 3-7 CONTRACTOR ' VS e I LA - t' PHONE l-� ! l/� L1 �►J CONTRACTOR ADDRESS � (A � CITYSTEU Z �� (a 0l535s� SUBCONTRACTOR/CONSULTANT / PHONE IN r SUBCONTRACTOR/CONSU�LTT TADDRESS CITY/STATElZ / �1 LICENSE _ C-57 YLi C-61 _ D-09 Other to 2/ NUMBER Z� V EXPIRATION DATE I BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL AMPLING: D General Mineral/Coliform Bacteria(4391) = Dibromochloropropane(4392)❑Arsenic(4393) s rINTENDED USE Domestic/Private Li Irrigation/Agricultural _ Industrial _ Water Quality Monitoring _ Soil Sampling/Characterization _ Public Water System If different from Owner. Water Svstem Name Contact Name or Phone Number TYPE C�WORK _ New Well U Replacement Well U Well Alteration/Modification _ Other Monitoring Well(s) #of wells i Soil Boring(s) #of borings - Geotechnical #of borings _ Out-Of-Service W II U Out-Of-Service Well Renewal Cross-Connection Repair New Pum Pum Replacement ❑ Pump Repair = Raise Well Casing WELL CONSTRUCTION Drilling Method _ Mud Rotary U Air Rotary : Auger _ Cable Tool U Push Point _ Other Proposed Well Depth ft Excavation in diameter -iOpen Bottom L Gravel Pack/Gravel Size in diamete _ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter— in Thickness/Gauge/ASTM Sched U Steel U Plastic _ Stainless Steel U Other �1 Grout Seal Depth ft n Neat Cement(94 Ib bag/5-10 gal water) - Sand Cement sack mix/7 gal water - Bentonite(20%solids) 7 Other Grout Placement Method - Pumped 5 Free Fall I-i Other Retardant/Accelerator(name) S PEDESTAL Installed By _- Driller U Pump Contractor Other _ Concrete Pedestal Dimensions:Width ft Len ft Thick in _ Christy Box U Stove Pipe <N PUMP - Submersible- Turbine '1 Other HP Pump Set ft Standing Water Level ft S 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. "IP UM 4 VANCE NOTICE REQUIRED FPRINSPECTIONS - PLEASE CALL (209 3-76a7 SIGNED _ TITLE Y V t.ev` DATE ii I I i i i I � I i I I N 4 �1�STH D P —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 l I DEPARTMENT USE ONLY Application Accepted By L� Date . lwalo Area �T�/ Employee ID# FR Grout Inspection By `` Date L SPECIAL Well Permit Pump Inspection By > f mxaj Lt) C�4nnr, %k +1_ Date \\119h!l_3 !, WAIVER Received Soil Boring In pection By Date Constructed Well Depth ft COMMENTS Boring -4e llf Uri PE Sc Received ec Amount Date Permit/ Invoice# Well ID# Codes Info B as Remitted Servic Request# 4381 oso s-n EHD 43-06 6/11/2019 WELL/PUMP PERMIT