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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 vr G www.S ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS y►3 i Lr I .V _-.--- CRY/ZIP :J 1 l'Vt�^ Mb-)". { Q-- _ APN_ .�-101 CROSS STREET _ _ARCEL SIZES S 7 LAND USE APPLICATION# � o OWNER NAME Sh L ( h N�1 o{' 1-h nd S('vA Vy 1 b,s-h/lc t PHONE [(q q�"��(��119-t)2 —[,/ . m OWNER ADDRESS 7 U 1 IV ka/&�i k �o �� CnY/STATEMP S ( 2nr ► ,t//T_ 01S: /` ) CONTRACTOR �CL l� ��,/ C P,0t�(.h PHONES 311 CONTRACTOR ADDRESS (�1J�� 1� ��(,I�y L( Cr Y/STATE9W � Q YJLI , SUBCONTRACTORICONSULTANT PHONE SUBCONTRACTORICONSULTANT ADDRESS Cf Y/STATEMP7 y LICENSE ,%!C-57 1 C-61 ❑D-09 = Other NUMBER 1 l Lr EXPIRATION DATE Jl� 101-2— BILLING PARTY. ❑OWNER _CONTRACTOR ❑ SUBCONTRACTORICONSULTANT DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)11 Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE n Domestic/Private - Irrigation/Agricultural ❑ Industrial ❑Water Quality Monitoring ,,Soil Sampling/Characterization U Public Water System If different from Omer. Water System Name Contact Name or Phone Number TYPE OF WORK n New Well it Replacement Well n Well Alteration/Modification ❑Other n Monitoring Well(s) #of wells %Soil Borings) i #of borings n.Geotechnical #of borings El Out-Of-Service Well ❑ Out-Of-Service Well Renewal :Cross-Connection Repair U New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary /Auger ❑Cable Tool ❑ Push Point U Other Proposed Well Depth 5 d It Excavation_ I in diameter L Open Bottom G Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth It Well Casing Diameter_in Thickness/Gauge/ASTM Schad ❑Steel ❑ Plastic ❑Stainless Steel 1 Other Grout Seal Depth!0 U,2k!21� f Neat Cement(94 lb bag/5-10 gal water) U Sand Cement sack mix/7 gal water ❑Bentonite(20%solids) ❑ Other Grout Placement Method X Pumped Free Fall U Other _ Retardant/Accelerator(name) PEDESTAL Installed By U Driller CI Pump Contractor ❑ Other ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in C 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 E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSA N LAWS\ MINIMU 4 RA NCE OTICE REQUIRED FOR 1 SPECTIONS-PLEASE CALL(209)953-7697 SIGNED TITLE DATE ' _ YMENT CES V ED 20 2021 (J/N C N P FNr LNT Y ARTMFNT DEPARTMENT USE ONLY Application Accepted By / Date (/�JId 1 Area &7AiiJCl<1'3✓t Employee ID# Grout Inspection By A r Date x f ❑ SPECIAL Well Permit Pump Inspection By Date I i WAIVER Received Soil Boring Inspection By I Date Const ucted Well Depth ft COMMENTS V l ` V'& n PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info Ca h Remitted Service Request# 37,2 1�:o EHD43-06 6/11/2019 , f��7'�� WELL/PUMP PERMIT