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'-- tiP/aoveb Pcn..--1 T 77 ml"It e w a//G c-e - r-vA/- t-6•� WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 NON-REFUNDABLE PERMIT WWW.sjgoy.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 61 e_pi �uS TSrm /� 531( }r 53�� n CROSS STREET /►Q L�/1tJ. tn..1 Z APN1 �7-07— O,,l�� O PARCEL�•ISIZE('/S•�/ 'LAND USE�1 PPLICAT/ION# �r�/(,/ A OWNER NAME A xko /� 'a iq L.1�'c- l KIT/U �(W of E 1 k l.,/4)_PHONE 7��y�` v31— v 7/ 0(/ tei OWNER ADDRESS 1010 ��A�O�/WI�J� J U (?TL `�v .CATTY/STATE/ZIP (PN_17 901-0�, t/—t 9O0 C CONTRACTOR _ JLI/0Db[. EX //Y/ Ar IcJ 71W� l/`�C� /(PHONE ` � / L 33 — �2� CONTRACTOR ADDRESS_ • Z r1 GW �� - CITY/STATE/ZIP (61Sp Alb C/ e 92� 9& 7 SUBCONTRACTOR/CONSULTANT Lo ALL A.I�L: qq�P //HONE ��o—3 Z "7�I7 ��ls y� SUBCONTRACTOR/CONSULTANT ADDRESS 3v � �( NO U5T/t-!M-L CITY/STATE/ZIP W I (`�t►J` v `K 15 SS LICENSE X-57 ❑ C-61 ❑ D-09 Il Other L U�NUMBER L EXPIR TIO�DA E IQ`/ 3G Z6"z BILLING PARTY: I OWNER CONTRACTOR UBCONTRACTORICONSULTANT INDOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392), .Arsenic(4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring Ksoil 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 wellsoil Boring(s) #of borings Geotechnical #of b ' gs ❑ Out-Of-Service Well ❑ 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 G_ft Excavation �_ in diameter D Open Bottom D Gravel Pack/Gravel Size 4n diameter ❑ Conductor Casing N {Ar in diameter / Conductor Casing Depth t4l l4 ft Well Casing DiameterN in Thickne-sss//Gauge/ASTM Sched J4)1q' ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water ❑ Bentonite(20%solids) ❑ Other 43 Grout Placement Method ❑ Pumped&ree Fall Other 1 1 ❑ Retardant/Accelerator(name) f PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal IlDimensions: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. MINIMUM 48 HOUR A NCE NOTICE REQUIRED FORINSPECTIONS -PLEASECALL(209)953-769/7/ SIGNE ' TITLE At 6✓I�e-r GtNG �NLG DATE VeD QA 2020 A U IV E 0UNn, MFNT DE A MENT� � UGE O LcY7n Application Accepted By _ Date I t/ L� Area Employee ID# ti Grout Inspection By Date SPECIAL Well Permit Pump Inspection By Date WAIVER Received Soil Boring Inspection By +T&,ve.5 Lo WCC- .,t- 1I li Date 11#2119 Constructed Well Depth ft COMMENTS PE SC Received Check Amount Date Permit/ Invoice# Well ID# Codes Info 141Y Cas Remitted Service Re uest# 52002-a- -10 WPOMI EHD 43-06 6/1112019 WELL/PUMP PERMIT