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r %s ., 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 JOB ADDRESS9 MaM Sk aJ U Mw Ave. CITY/ZIP ';_�OCL,O Ist I� m IAL 11- I D CROSS STREET ►}?.�J / It�.:r Atc APN l yl- 160 " 610 PARCEL SIZECLAND USE APPLICATION# p M OWNER NAME I�.OG�{f�/ (_�ft�► �.5� R�f PHONE N OWNER ADDRESS aq(o 1 `-•'e po k 1"`�'1 - / CITY/STATE/ZIP cjI O CONTRACTOR 1 "Q��V(►1��,f QII1Q 7WScr/� ,.1_PQHOONEQ, 3 (l Q CONTRACTOR ADDRESS 0D o `,M�'US�r`Q"� �( CITY/STATE/ZIP Wpm` .ilw�w•�/.��. GA �Se9f SUBCONTRACTOR/CONSULTANT �rdltnq PHONE/�'�{J A(' • � /700 SUBCONTRACTOR/CONSULTANT ADDRESS 11% 4 I 1 6jr5 �� CITY/ST QATE/ZIP 641� VAS 1<6;z- LICENSE <6;"J"- LICENSE �-57 LI C-61 U D-09 L Other NUMBER ZO `D EXPIRATION DATE �Z BILLING PARTY: LJ OWNER CONTRACTOR L SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: 11 General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)iJ Arsenic(4393) INTENDED USE L Domestic/Private L Irrigation/Agricultural L Industrial U Water Quality Monitoring Soil Sampling/Characterization 1:1 Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well I Replacement Well Fl Well Alteration/Modification U Other Monitoring Wells) #of wells YSoil Boring(s) 11111 #of borings �OGeotechnical 3 #of borings Out-Of-Service Well I I Out-Of-Service Well Renewal ❑ Cross-Connection Repair New Pump a Pump Replacement i I Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method) U Mud Rotary U Air Rotary +Auger U Cable Tool ❑ Push Point U Other Proposed Well Depth1�; ft Excavation & in diameter U Open Bottom U Gravel Pack/Gravel Size in diameter I i Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic U Stainless Steel P Other Grout Seal DepthI!r- ft , JNeat Cement(94 Ib bag/5-10 gal water) U Sand Cement sack mix/7 gal water f I Bentonite(20%solids) ❑ Other Grout Placement Method I] Pumped ree Fall i i Other ❑ Retardant/Accelerator(name) PEDES AL Installed By Cl Driller ❑ Pump Contractor ❑ Other L Concrete Pedestal FJDimensions:Width ft Length ft Thick in U Christy Box a Stove Pipe PUMPMW L Submersible L Turbine U 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. 1 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL. (209) 953-^76997 SIGNED TITLE a� GdolvS� DATE P HD A T 4 E T I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I DEPARTMENT USE ONLY Application Accepted By L.Z_ Date .-, - Area a 99 Employee ID# Grout Inspection By . Date G SPECIAL Well Permit Pump Inspection By Date LI WAIVER Received Soil Boring Inspection B i Date Constructed Well Depth ft COMMENTS e � � S rl 1 L° N O PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Infoy Cash Remitted Service Request# y37 IS0 760 to•tial IQ W EHD 43-06 6/11/2019 WELL/PUMP PERMIT