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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 96205-6232(209)468-3420, NON-REFUNDABLE PERMIT www.S Oy.OE1ehd 1YZEXPIRES 1 YEAR FRO ATE ISSUED JOB ADDRESS CrI P CROSS STREET APN )3z)3 3�3 PARCEL S� I�' LAND USE APPLICATION# o C t// �{ r / �^ ^/I�C�1 r m OWNER NAME ��.1 ` (/I VY�I 1 1 (JG(.V` 11�(.�lV `L F_/ PHONE,.[.,V 1 I.•- ��[7,\y- OWNERADDRESS ( In') e '^— CRYISTATEZP CONTRACTOR = i1 / �,//�ti I (�� I��I/l�I y I/\ PHONE ,/V /� CONTRACTOR ADDRESS U `/V�`1- I —1 `�1 ll� CITYISTATEZP K I i/�.(/t I ('I SUBCONTRACTORICONSULTANT V tPHONE �-+r SUBCONTRACTORICONSULTANT ADDRESS CITY,/STATEZ LICENSE 7 ❑C•61 ❑D-09 ❑Other NUMBER � `� ` ` �'IRATION DATE`-1 BILLING PARTY: ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTORICONSULTANT DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)0 Arsenic(4393) INTENDED USE ❑DomesticJPrivate XirrigabontAgricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System �/If different from Ovmer Water System Name Contac Name or Phone Number Iy TYPE OF WORK NBw Well ❑Replacement Well ❑Well AtteratlONModificabon ❑Other �`_� ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #.Ib ring ❑Geotechnical of borings �/ e/V/ ❑Out-Of-Service Well ❑Out-OfS � /r ervioe Well Renewal ❑Cross-Connection Repair ec 0 New Pum ❑Pum Replacement D Pum Repair ❑Raise Well Casingy IV�D ✓ WELL CONSTRUCTION Drilling Method)(Mud Rotary ClAir Rotary 0 Auger ❑Cable Tool ❑Push Point ❑ Other SEP O �O Proposed Well Depth� ft� Excavation in diameter D Open Bottom ❑Gravel Pack/Gravel Size in dia 20 0 Ctlu or Casing in diameter / Conductor Casing Depth ft JO,q(�V�N Well Casing Diameter n Thi71 dmess/Gauge/ASTM Sche4� ❑Steel Plastic ❑Stainless Steel ❑Other /�O COVN Grout Seal Depth ft ❑Neat Cement(94 Ib bag15-10 gal water) ❑Sand Cement sack mixl7 gal wa r TH NMEAM Bentonite(20%solids) ❑Other Of P'�T�1. Grout Placemen Method Pumped ❑Free Fall 0 Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller Pump Contractor ❑ Other ❑Concrete Pedestal❑Dimensions:Width it Length It Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible❑Turbine 0 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 COMPUANCE WITH ALL WORKERS COM NSATION LAWS. MINI U UR ADVANCE E NOTICE REQUIRED FOfLINSPKTJONNS-PLEASE CALL(209)953 7697 SIGNED c 1 TITLE u "y► DATE CA NA A DEPARTMENT USE ONLY i Application Accepted By C� � Date C J Area �� Employee ID#� Grout Inspection By ACyu-•S(- s.• .1 rv—L- Data '1 1(Grt✓lw 0 SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received 2 0 Soil Boring Inspection By Date CoryS acted WeJI Depth L h COMMENTS r0 •VIP�t'I' O 1�T +E7 r k -�r r-•�-r- C� 0 �{- 4•,. S '� ._Cor lin 'Jin O�ItLl l wOS� rr✓t PE SC Received Chec Amount Date Permit/ Invoice# Well ID# Codes Info By Remitted Service Reciuest# EHD43-06 6/112019 WELL/PUMP PERMIT