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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-REFUNDAB PERMIT WWW.sjgov.org/ehci EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS Q 1 I 1 I ✓S �j ')QCITY/ P "V' CA y�� -7m CROSS STREET J T PN d O7 L r D PARCEL SIZE LAND USE APPLICATION# v a ice U�� W 3 OWNER NAME PHO �j //�� {J NE /� ''J y OWNER ADDRESS / / m V !� CITY/STAT /ZIP ( qS'S - CONTRACTOR Int c l� �n vi r 1 C PHONNE" ` c�q J 6J-0 CONTRACTOR ADDRESS SV ` i t- �� CITY/STATE/ 1 4C� ! V C6 v/S_2C 1) !y SUBCONTRACTOR/CONSULTANT PHONE b� f J� f SUBCONTRACTOR/CONSULTANT ADDRESS � ] CITY/STATE/ZIP / { A 7 LICENSE _ C-57 VC-61 _ D-09 ❑ Other ��1 NUMBER2-7(70 EXPIRATION DATE[ U 1 BILLING PARTY: OWNER V,CONTRACTOR - SUBCONTRACTOR/CONSULTANT DOMESTIC WE L SAMPLING: ❑General Mineral/Coliform Bacteria (4391)- Dibromochloropropane(4392) ❑ Arsenic(4393) INTENDED USE Domestic/Private U Irrigation/Agricultural _ Industrial Water Quality Monitoring _ Soil Sampling/Characterization _ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK _ New Well a Replacement Well L Well Alteration/Modification _I Other - Monitoring Well(s) #of wells n Soil Borings) #of borings - Geotechnical #of borings _ Out-Of-Service Well a Out-Of-Service Well Renewal J Cross-Connection Repair - New Pump Xpump Replacement ❑ Pump Repair F Raise Well Casing WELL CONSTRUCTION Drilling Method _ Mud Rotary Li Air Rotary a Auger _ Cable Tool I_ Push Point Other Proposed Well Depth ft Excavation in diameter _j Open Bottom L Gravel Pack/Gravel Size in diameter _ Conductor Casing in diameter ! Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Sched _i Steel L Plastic _ Stainless Steel U Other Grout Seal Depth _ft n Neat Cement(94 lb bag/5-10 gal water) n Sand Cement sack mix/7 gal water - Bentonite(20%solids) 7 Other Grout Placement Method - Pumped n Free Fall Other r': Retardant/Accelerator(name) PEDESTAL Installed By - Driller D Pump Contractor C Other _ Concrete Pedestal UDimensions:Width ft Len ft Thick in Christy Box U Stove Pipe PUMP - Submersible- Turbine n Other HP tq 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 /AIND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT ! AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAW Z i,. INlIM 48 HOU DVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209)'04t 19 SIGNED TLE ✓ �` man L IyI DATE DI V �K N IR0N%MqE TA HE R M .Vi u 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 t I I I I I I I I I I I i I DEPARTM ENT USE O N L Y Application Accepted By � Date h c7 1_2b Area Employee ID# F/Znn Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By �.� �� i n,.\, ;1 Date 7_6j LF'LI< ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info By Cash Remitted I Service Request# 3$ 05-0 L4b �* 7 lJ x EHD43-06 6/11/.2019 WELL/PUMP PERMIT