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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 1. 774 ',lJ �(< to JOB ADDRESS 8J 1 V h CITY/ZIP J m ty�/�I I D CROSS STREET / '_ tiyt APN I! 4- I10' Vo PARCEL SIZE;?.q Z LAND USE APPLICATION# z Q LGG N OWNER NAME /�)�J� y1 /n'' nPn U/P��1�'U/f'�- ��roup PHONE OWNER ADDRESS IGLOO 1 1., Ltie \J CA,r� I1 CITY/STATE/ZIP ��+1I ! l7 go CONTRACTOR I,7All" _ bill►1 448 A nis A PHHONE Nff QT►�/ " 3q(7 CONTRACTOR ADDRESS �0SD (�,/'Lt1S\�1 ra� 'JtJ ++ CITY/STATE/ZIP OL SaamI,Iy1G}I1�rL� e �g616 1 I SUBCONTRACTOR/CONSULTANT U Q,J WSJ �lr{�u,1�yll, PHONE (V ` D7-' -7/t0 SUBCONTRACTOR/CONSULTANT ADDRESS tj J3 IJYU�e -�'J 0r4 CITY/STATE/ZIP � LICENSE D 57 -1 C-61 L D-09 ! Other NUMBER /�P { EXPIRATION DATE Ind'�i(z BILLING PARTY: J OWNER NfCONTRACTOR ! SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: I I General Mineral/Coliform Bacteria (4391)f_] Dibromochloropropane(4392)11 Arsenic(4393) INTENDED USE J Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring oil Sampling/Characterization 1.1 Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK I 1 New Well I 1 Replacement Well I.1 Well Alteration/Modification I I Other Li Monitoring Well(s) #of wells i7 Soil Boring(s) #of borings Geotechnical�_#of borings 11 Out-Of-Service Well I I Out-Of-Service Well Renewal ❑ Cross-Connection Repair I I New Pump Pump Replacement U Pump Repair D Raise Well Casing WELL CONSTRUCTION Drilling Method a Mud Rotary L Air Rotary Auger L Cable Tool ❑ Push Point 0 Other Proposed Well Depth1�5'_ft Excavation - (g in diameter a Open Bottom J Gravel Pack/Gravel Size in diameter Conduct Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched 1 Steel I Plastic Stainless Steel Other Grout Seal Depth ft eat Cement(94 Ib bag/5-10 gal water) J Sand Cement sack mix/7 gal water U Bentonite(20%solids) 1 1 Other Grout Placement Method C] Pumped KFree Fall I I Other I I Retardant/Accelerator(name) PEDESTAL Installed By I Driller Ll Pump Contractor 1 1 Other L Concrete Pedestal Li Dimensions:Width ft Length ft Thick in IJ Christy Box ❑ Stove Pipe PUMP Submersible Turbine L, Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT 1 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 M 8 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTION -PLEASE CALL (209) 953-76. 7 SIGNED TITLE V� FJ� DATE !go T W EV H L H E R M N —————— ————————— ————-- I LL I I I DEPARTMENT USE ONLY Application Accepted By I_ z-, L Date 10 ./y X4ZO Area -1 1 Employee ID# D Q Grout Inspection By Date 3 2 ?a ❑ SPECIAL Well Permit Pump Inspection By Date 1 WAIVER Received Soil Boring Insp tion By Date Constructed Well Depth ft COMMENTS (0 VoL+e-cC 'Ed PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info Cash Remitted Service Request# 1-001 111;0S • Z EHD 43-06 6/11/2019 WELL/PUMP PERMIT