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WE .1-.1PUMP F'C,RMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 FAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 14ON-REFUNDAB �PERMIT _ _ W �s,�1a14� O�t��tt�---- E)' PI S 1 YEAR FROM DATE ISSUED _ m joB ADDRESS _ ---- - --..- - --- ---- -- •.r?Oa5 STREET _ �'�^ 1�a. _SL-._✓ ' AF:CEL SIZ.E ! / La•ND I.jSE APPLICATION# ,- Im I �i p ,/J�-- ' -- �! #� I r b_ �l l U! ! s ►C. _ _ - IIDNE __ I i OWNER NAME t _ IV�I J _ 1� - _ _ - C!_`'/STATE/'I rci' ✓ �-� 1.1T _ - �14 S - �C P HOS.�-�V -P 5)NI -1 1:2VdlO y. 1,0NTRACTOR. --- _----- .-� CITY PHONE i:.�UBCONTP,ACTORIOONSULTANT_ - -_—__ -- --- : CIGONSL� rAADRESS - ^IPC% ISATEJZ SUBCDYrRACTiR�1 ke [ i LICENSE C-5: -8'I NUMBER EfP1RA-T0 .N.—OA-,E Lj3-—�7-o- 31LUNG PARTY: OWNER (C'ATRiCTOF SUBCOTRAGiOWiON$ULTANT J � nom, --arS2r1G 1[430,3)Dio :_,ab7ne (4392)::;L=87)C ". i C "ltr :;g; .haracterization KTGNDEDUSF Dmest,ciPr!vab - l.-rigabonfAgricultural Industrial _ Water Quality Monitoring -. SoilSampli E .f ai Terent From Opener:Public Water -_-�- lJater System iJame Conact Name or Phone Number --�� TYPE OF WORK _ New Well Replacement`JVFII _ Well Alteration/Modification _ Other - # - Monitoring Weli(s)^__--#of Wells - Soil Boringof borings Geotechnical of borings s), _ Out-Of-Servic W II Out-Of-Service Well Renewal - Cross-Connection Repair _ = New Pump Pump Replacement Pump Repair_ - Raise Well Casing WELT-CONS ERUCL11 N = Drilling Method _. Mud Rotary = Air Rotary _ Auger - Cable Teo! Push Poirr _ Other _•_.-._... (Proposed Well Depth_-_-- `t Exr.avatiom -_•��__- in diameter _ Open Bottom Gravel Pack/Gravei Size---in diameter; I r h Conductor Casing_- 'iaineter i Conductor Casing Depth '61 Casing Diameter_—, in t hicr'nasslGau i>.J;, TPf Schell •____- _ Steel Plastic _ Stainless Steel _: Other---- ther `- i O Grcut Seal Depth ft Nle�:at ':ornent (9414,bag/5-9:gal water) Sand Cement—_ ,,,--„_._.Sack,1,N gal water _ Bentonite;20%solid's) Other__ __ -- ---------I l I Grou+.Placement MethodPurnped Free Fall Other —_- - Retardant/Accelerator(name)__-._� _ l PEDESTAL Installed By Diller Pump Contractor Other - ---- - ! - Concrete Pedestal -Dimensions:Width ft Len th ft Thick in _ Christy Box Stove Pipe _ ! PUMP Submersible- Turbine 7 Other HP_ Pump Set ft Standing Water Level _ fit 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 CT VE- WITH THE CALIFORNlr=1 CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALI fa 6 C4'O44R, ''"'iv}CE > OT110E REQUIRED FO�MPECTIONS �PLEASE CA,4. (209)t9 76 Zb SIGNED TITLE � `"- � DATE - PCE I i I �— -I I I - i-- -- - ; } --i--r- —�--i l ' I I 60Td i Y h --i - - I�ONAIIEN-T'AL- T1H DE ENT I i l�� --•,---_1 1 1 1 1 1 1 i - -1-- DEPARTMENT USE ONLY Application Accepted By Date0ti dvd6 Area S Employee ID# _ Grout Inspection By �^ _ Date El SPECIAL Well Permit Pump Inspection By ks&U-". Date I I WAIVEF: Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info Cash Remitted 3ervice Re uest# 391 O a 2 7 EHD 43-06 6/11/2019 WELL/PUMP PERMIT