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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 ADDRESS CITY/ZIP ` I V m ///�� ✓ q D CROSS STREET � APN Q�5 d 7075 PARCEL SIZE �•C� LAND USE APPLICATION# rn OWNER NAME PHONE00 N OWNER ADDRESS CITY/STATE/ZIPLwtc8A:—ea�4n CONTRACTOR LAM PHONFC�M [- '3a rD CONTRACTOR ADDRESS W./ 1 CITY/STATE/ZIP 5 a l A5 SUBCONTRACTOR/CONSULTANT :) Z4 PHONE ) �^ SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP LICENSE KC-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 46@9_�g - EXPIRATION DATE BILLING PARTY: ❑OWNER ❑CONTRACTOR ❑ 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 ❑ 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 ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft I HEREBY CE IFY 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 WORKER OMPENSATION LAWS. (M?Z M HO VANCE NOTICE REQUIRED FOR NSPEC IONS -PLEASE CALL (2097 -76 7 SIGNED TITLE DATE ✓ q C 'DEPARTMENT USE ONLY O�RrMF Application Accepted By L Date bZ-70a�o Area LlIq Employee ID# Grout Inspection By { Date ❑ SPECIAL Well Permit Pump Inspection By Date 1 (2;,Lt ❑ 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 Service Request# EHD 43-06 6/11/2019 WELL/PUMP PERMIT