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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.orq/ehd EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CITYizIp CROSS STREET ,. / ^/APN PARCEL SIZE! , bc( LAND USE APPLICATIIIOON?# (�L C, 7 OWNER NAME -CMI/V 114A-) ;214LU%C, PHONE -2L91- (7 J O Jtj�7 OWNER ADDRESS j /, 3 J _) G, ) V002 I �n_- CITY/STATE/ZIP e,1 Z_1tA) CONTRACTOR CONTRACTOR ADDRESS �,`' CITY/ST SUBCONTRACTOR/CONSULTANT SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP PHONE _(901- 9V PHONE LICENSE I I C-57 AC -61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE BILLING PARTY: 141 OWNER ❑ CONTRACTOR I I SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization i i Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK New Well Replacement Well ❑ Well Alteration/Modification ❑ Other '1 Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings I Geotechnical # of borings Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair New Pump i Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method i i Mud Rotary l Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation in diameter [ I 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 ❑ Steel ❑ Plastic ❑ Stainless Steel I i Other Grout Seal Depth ft I i Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water i I Bentonite (20% solids) ❑ Other Grout Placement Method ❑ Pumped CI Free Fall ❑ Other I Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor X Other Concrete Pedestal ❑Dimensions: Width __aL ft Length ft Thick LV in ❑ Christy Box ❑ Stove Pipe PUMP Submersible [-I Turbine ❑ Other HP I Pump Set--LZO 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. M IMUM 48 > RA VANCE NOTICE REQUIRED FOR INSPfCTIONS - PLEASE CALL (209) 953-7697 J SIGNED�nw TITLE DATE DATE ��-�/ ` PARTMENT USE ONLY Application Accepted By I V Date 7? 3 L 1 Grout Inspection By W J Date Pump Inspection By Ertiti`. s (a (y r; tJ _t_ Date Soil Boring Inspection By Date COMMENTS Area �tkq Employee ID# " SPECIAL Well Permit WAIVER Received Constructed Well Depth ft PE SC Received Check Amount Date Permit/ Invoice # Well ID# Codes Info By Cas Remitted Service Re uest # �52- til W EHD 43-06 6/11/2019 WELL /PUMP PERMIT m D v v A m lz.