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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 N JOB ADDRESS CRY21P L� m D CROSS STREET APN C)C>I U 3 Q PARCEL SIZE 51 •I LAND USE APPLICATION# O �^ A OWNER NAME I Q t r 1 t I \Q v�L'. ' i/�L �� PHONE y OWNER ADDRESS P0 (3c c 7C i O O O L'o, (.4 / 1 CrrY/STATE/ZIP �)�; 1 CONTRACTOR rV�,� lI �.-�c��.US�nII` TCJ�c�C�.� lin\.��c,,.)\ 17 t PHONE ✓C`, 3L-i I CONTRACTOR ADDRESS CITY/STATE/ZIP 71`1 D SUBCONTRACTOR/CONSULTANT PHONE SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP LICENSE 'jr C-57 ❑ C-61 D-09 Other NUMBER Cc U c(C C`i EXPIRATION DATE L, t a 1 BILLING PARTY: ❑OWNER CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING:Li General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)- Arsenic(4393) INTENDED USE ❑ Domestic/Private Irrigation/Agricultural Industrial 'i Water Quality Monitoring X Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK q New Well Replacement Well ❑ Well Alteration/Modification Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings X Geotechnical S #of borings ❑ 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 ?c Auger Cable Tool Push Point - Other Proposed Well Depth I ft Excavation in diameter IOpen 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 X Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water Bentonite(20%solids) Other Grout Placement Method Pumped X 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. MINIMUM 48 HO ADVANCE NOTICE REQUIRED FOR INSPECTIONS -`PLEASE CALL(209)953-7697 SIGNED TITLE CIr 2C)4o1 DATE 1) K;. S q 20 r ry r DEPARTMENT USE ONLY Application Accepted By Date G l l� Area � / ' Employee ID# Grout Inspection By t 1 — Date ';� ❑ SPECIAL Well Permit Pump Inspection By Dace WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS _1 t ct,L'rGIllC� Fr IS r;�� n PVP fYPvnl l F r(�� LP ozF(-� PE SC Received h Amount Date PermlU Invoice# Well ID# Codes Info B ash Remitted Service Request# LIS 7a 12 2 zo Po EHD 43-06 6/11/2019 WELL/PUMP PERMIT