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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 JOB ADDREESSi L�m�S�`/fes_ CITY/ZIP � 17�b l m CROSS STREET W�G.CJI Lt'\ APN —V�l J D � LSS _J C f PARCEL SIZE LAND USE APPLICATION# Cn OWNER NAME M//p `�,tit�Jrl d44 VI✓KA �UY�rj C PHONE ry N OWNER ADDRESS .3 W n CkCITY/STATE/ZIP J�ko� I S;:�7J �( CONTRACTOR A�G — ( nSGL PHONE al�� `17-! — ��TI 7 / CONTRACTOR ADDRESS (�I�Ulal VOf CITY/STATE/ZIPLl( 1 r lJ�I l ?W SUBCONTRACTOR/CONSULTANT rC)r1 �1/ /r. ;��J PHONE q / -Z SUBCONTRACTOR/CONSULTANT ADDRESS I(3 Z [SlaLG�L K, Dr CITY/STATE/ZIP (7Q( � ` ( I l,�.��''\\ LICENSE A_C-57 Li C-61 D-09 � Other NUMBER n U` EXPIRATION DATE '�U !tom LL BILLING PARTY: iJ OWNER `,IKCONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: ! 1 General Mineral/Coliform Bacteria (4391)I I Dibromochloropropane(4392)I I Arsenic(4393) INTENDED USE _i Domestic/Private i-, Irrigation/Agricultural L Industrial -1 Water Quality Monitoring '�Zoil Sampling/Characterization I Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK i i New Well I I Replacement Well I Well Alteration/Modification ❑ Other AL1 Monitoring Well(s) #of wells KSoil Boring(s) AN #of borings Geotechnical 2,#of borings I Out-Of-Service Well i i Out-Of-Service Well Renewal i! Cross-Connection Repair I i New Pump I Pump Replacement i Pump Repair i I Raise Well Casing WELL CONSTRUCTION Drilling Method G Mud Rotary Air Rotary g Auger iJ Cable Tool L Push Point _i Other Proposed Well Depth 15 ft Excavation 6 in diameter U Open Bottom Gravel Pack/Gravel Size in diameter I Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched I Steel Plastic F, Stainless Steel ii Other Grout Seal Depth1 15, ft Neat Cement(94 Ib bag/5-10 gal water) J Sand Cement sack mix/7 gal water Bentonite(20%solids) Other Grout Placement Method a Pumped Free Fall 1 Other F Retardant/Accelerator(name) PEDESTAL Installed By Driller Pump Contractor Other j Concrete Pedestal Dimensions:Width ft Length ft Thick in J Christy Box 7 Stove Pipe PUMP P( _ Submersible Turbine a 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 COLNTY 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. MUM 8 HOUR ADVANCE NOTICE REQUIRED FOR INS CTIONS -PLEASE CALL (209) 95 -76 7 SIGNED TITLE DATE ENI HIAL rH EAT EN 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 p Application Accepted By Date l0/%yld — Area a / Employee ID#DA Grout Inspection By L�Sios (pate Lo w C' SPECIAL Well Permit Pump Inspection By Date I WAIVER Received Soil Boring Inspection By � pate Constructed Well Depth ft COMMENTS J YUUf � Zt/�f! l/ G'If4 'L((/d6✓t- PE Sc Received Check#/ Amount Permit/ Codes Info y Cas Remitted Date Service Request# Invoice# Well ID# 3 70 i o s/ i6o l 20 3 EHD 43-06 6/11/2019 WELL/PUMP PERMIT