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i 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 l?� JOB ADDRESS lr� �OS�2•L CITY/ZIP ottzjg'- I N m p. D CROSS STREET_-4 V� N �7( _APN �/ / -7 ZD..YAP-06--p PARCEL SIZE 67.7 AC LAND USE APPLICATION# O y m OWNER NAME (,Dw)ZIa L/{ (LL PHONE OWNER ADDRESS _Ilea loffuelakr 1-1 NE rTj 1000 CITY/STATE/ZIPlr CONTRACTOR I fi✓ �..(y _ `� '14 PHONE[2,04 761'— 710P CONTRACTOR ADDRESS / y � ({�g,ieeT oa- CITY/STATE/ZIP �'�f (,K CIT-0.j2— SUBCONTRACTO NSU WIj1t��kCf—�VYII. 4 +S}O(k+jE/ PHONE (b 3'7L`1/J(( SUBCONTRACTOR/CONSULTANT ADDRESS 30fU /A/�,Jr.yl�` rIV�D CITY/STATE/ZIP aE/l }M6'-j'p, CA `f 6W LICENSE XC ❑ C-61 11D-09 11 Other NUMBER 7* ip 0 EXPIRATION DATE BILLING PARITY: OWNER CONTRACTORUBCONTRACTOi�` LT DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392), Arsenic(4393) INTENDED USE rl Domestic/Private 0i Irrigation/Agricultural ❑ Industrial I i Water Quality Monitoring XP Soil Sampling/Characterization rl Public Water System _ If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK 11 New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other _ 11 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings %";eoterhnical $ #of borings C 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 11 Air Rotary Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth 20 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 11 Steel Ll Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth__ ft 'Neat Cement(94 115 bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water ❑ Bentonite(2.0%solids) ❑ Other Grout Placement Method 11 Pumped 1.1 Free Fall 40ther T/LC'Ml E i1 Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor 0 Other El Concrete Pedestal❑Dimensions:Width it Length ft Thick in ❑ Christy Box ❑ Stove Pipe [PuMr> ❑ Submersibleu 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 ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 963-7697 SIGNED _ TITLE�i-E O L QG-1 iy DATE /b/7-0 Z� T DEPARTMENT USE ONLY Application Accepted By ojjr--)4 ( Date ZA0 Area ©� Employee ID# Grout Inspection By_ Date SPECIAL Well Permit Pump Inspection By { f Date WAIVER Received Soil Boring Inspection By kYA,nt r La \ neo A1_ Date 1 2i? Constructed Well Depth _ ft COMMENTS _— PE SC Received CChecW Amount Date Permit/ Invoice# Well ID# Codes Info ev U-ash Remitted Service Request# �52 / t a b --- EHD 43-06 6111/2019 WELL/PUMP PERMIT