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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/ehdX PIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CITY/ZIP m O _/ /� �i D CROSS STREE APN oO��(-n v�� PARCEL SIZE `I I LAND USE APPL�IiCATIOONN�# o [ m OWNER NAME PHONE {� N OWNER ADDRE Pe>' kL� 1 CITY/STATE/ZIP (fi 9 7 CONTRACTOR Y PHONE�>lJ� ��Z CONTRACTOR ADDRESS CITY/STATE/ZIP (A 9CO�7 SUBCONTRACTOR/CONSULTANT 11A PHONE SUBCONTRA T R/CONSULTANT ADDRESS /C1TY/STATE/ZIP LICENSE -57 1], C-61 ❑ D-09 11Other NUMBER L{//—l/ EXPIRATION DATE �l/( BILLING P PRTY'.' FOWNER ❑CONTRACTOR J SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: P. General Mineral/Coliform Bacteria (4391) Ci Dibromochloropropane(4392) ❑ Arsenic(4393) INTENDED USE Domestic/Private ❑ 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 Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal C] Cross-Connection Repair ❑ New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION IL Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool J Push Point J 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 Contracto- ❑ Other ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersible❑ Turbine LI Other HP Pump Set /Z' 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. MI H�VANC.ETICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 95 -76 7 SIGNED TITLEDATE Ln DEPARTMENT USE ONLY HOEpgRrAf' Applicatuon Accepted By Date 107dua0 Area Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By (re 4r+ C t0 T— Date li/>s��z c' C WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Receivedheck#/ Amount Date Permit/ Invoice# Well ID# Codes Info I By C—a—sh Remitted I Service Request# Ll 3- 1 05-0 (� 'oZ 7 l� 2-0 uf 1311 EHD 43-06 6/11/2019 WELL/PUMP PERMIT