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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.sigov.org/ohd EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS _ l�l S t'l-�/�1�/ '/7 CITY/]JP L l�1 c: CI CROSS STREET_L C Ct�L\ ,/l` V` APN JC 5 Q I� PARCEL SIZE LAND USE�APP,PLICATION#\ 1 -'1 o OWNER NAME ED 1�'(-1 )±C.nC Si�77rT�csG ue- (PHONE ,x'1/.-�'��\��i(1�-G 1 �?:1/ "y OWNER ADDRESS I CI C` I C., )��v 'S 7 CITY/STATE(LP LC 1 I l Q/-1 -1 J,C;� -IC CONTRACTOR \1 1\/� 17�i \ `1^Y\ PHONE37Q937Q (I'- �77 I// < CONTRACTOR ADDRESS C.r 1.7 CI 7C `l CITYISTATEZP C-C'1 {t l ` A CA 5 b 5 2 SUBCONTRACTOR/CONSULTANT PHONE SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATEEZP "�7 '1 LICENSE C-57 -1 C-61 0 D-09 0 Other NUMBER 7C C J S ExPIRATION DATE / -3 ) - Jf c, BILLING PARTY: 0 OWNER ,CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING:,)(General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)0 Arsenic(4393) INTENDED USE X DomesGdPrivate Irrigation/Agricultural Industrial - Water Quality Monitoring - Soil 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 WeII(s) #of wells Soil Boring(s) a of bongs Geotechnical #of borings Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair New Pump G Pump Replacement Pump Repair Raise Well Casing WELL CONSTRUCTION Drilling Method/,4,Mud Rotary i-.Air Rotary .Auger Cable Tool Push Point Other Proposed Well Depth 3C'5 ft Excavation ) ? in diameter Open Bottom X Gravel Pack/Gravel Size 1/4 in diameter Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter G in Thickness/Gauge/ASTM Sched C\7C.% C�Steel 'j_Plastic Stainless Steel _,Other Grout Seal Depth JC CI It _Neat Cement(94 1b bag/5-10 gal wafer) ;KSand Cement {0 S sack mixf7 gal water -.Bentonite(20%Sollds) Other Grout Placement Method Pumped _Free Fall -Other =Retardant/Accelerator(name) PEDESTAL Installed By )�,Dnller Pump Contractor D Other ,(Concrete Pedestal�-0imensions.Width 2 _ft Length__j_it Thick in Christy Box c Stove Pipe PUMP Submersible Turbine ._Other HP__2 Pump Se[__�,S tt Standing Water Level 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 ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED�C>�Y '�2•til�+'� TITLE \i C '� r C S rl + DATE W P ne LoCc,S RV w T �i 11 LJ f •L v r U 5 E - RE SAShv�Rp�PpRTM DEPARTMENT USE ONLY � = H�P�jN Application Accepted By � '" � Date F 3C; ratJtJ�O Area E / mployee ID# L) Grout Inspection By �Nt.S tr [c..it,.E- It Date -71 11t 1 I Lip IJ 'SPECIAL Well Perninit Pump Inspection By " r i,.11 )l.i (;ia 11'14,Mu L Date [h u L /'v 0 WAIVER Received Soil Boring Inspect n By Date Constructed Well Depth ft COMMENTS N<' !/fit/d. lam t</ynl o` St'62.:� ule� /! nt �!T/S f,i'•t PE SC Received Check#/ Amount Peri Codes Info Ceah Remitted Date Service R—,,..,e Invoice# Well ID# 3e I #Ise la Wp 0 y00 21 a,�6E. c7 4s'J 6 ti3 Al2— c, J L Q EHO 40-06 6/112019 1/ VIFI L/PUMP PERMIT ,Jy/ Cl -41)b2-62-z,5-