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WELL/Ra ROP P�pFRN11T SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT '1868.FAST HAZELTON AVENUE-'STOCKTON CA 95205.6232 (209)468-3420 BION-REFUNDA LE PE11II'MI-1 _ b4ww.S (d`.o! /ehdE,�X1_P��rRE�S 'I YEAR FROM DATE ISSUED IOB ADr R ss -- D ` b� ��j2 � CrrrrZlI Y/C ( �J_ m !CROSS STREET • �APN a0907011 c a PARCEL SIZE + LAND USE APPLICATION# a burr - - -- c� - - . - y OWNER NAME _ -A ` PHONE-- m 'OWNER ADDRESS ✓V✓ 1 1 a I CITY/STATE IP� �CA rt , V r�e/ ) P!/1 �- PHONE "� CONTRACTOR . /vt j�P /� r� _._-_ CITY/STATED Y �l 5 CONTRACTOR ADDRESS -1� 44 _ _ LJ 1 KAI I.i^.UBCO��lTRACTORICONSULTAN7 ,1r l PHOM1I� t Y SUBCONTR.AC-TOR/CONSULrANTADDRESS ` _ CITY/STATE/ZIP N D (' (LICENSE. _ C57 YC-61 _ D-09 _ OtherNUMBER Q�/�lO6tr OEXPIRATIONDATElo vC , _ I `BILUNC PARTY: —_OWNER VONTRACTOR SUBCONTRACTOR/CONSULTANT — i DomEsncVVELLSAMPLING: . General Mineral/Coli'Orm Bacteria (4391)= Dibromochloropropane(4392)L Arsenic(4393) INTENDED USE - amestic/Private _: Irrigation/Agricultural _ Industrial _ Water Quality Monitoring _ Soil Sampling/Charactenzation --- _ Public Water System I! If different from Owner. Water System Name Contact Name or Phone Number TYPE OF WORK - New Well Replacement Well _ Well Alteration/Modification _ Other .0 ft of borings ;'of borings Monitoring Well(s)v_rt of wells - Soil Borings) - - Geotechnical - Out-Of-Servic W911 _ Out-Of-Service Well Renewal _ Cross-Connection Repair -- New Pump V ump Replacement :: Pump Repair _ Raise Well Casing !WELL CONSTRUCTION I Drilling Method _ Mud Rotary _ Air Rotary _ Auger __ Cable Tool _ Push Point _ Other I ?roposed Well Depth ft Excavation -_ in diameter Open Bottom :_ Gravel Pack/Gravel Size_ in diameter' _ Conductor Casing_—�in diameter / Conductor Casing Depth Weill Casing Diameter in Thickness/Gauge/ASTM Schad _: Steel Plastic, - Stainless Steel Other I Grout Seal Depth _�_•�fl _ Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water Bentonite(20%solids) _ Other i ;Grout Placeme+t Menhod=Pumped 7 Free Fall : Other _ - Retardant/Accelerator(name) PEDESTAL installed By -- Drilier Pump Contractor Other Concrete Pedestal-f-imensions:Width ft Leng _ ft Thick in _ Christy Box _ Stove Pip j M _- _ Submersible- Turbine 7 Other _— HP Pump Set-VV it Standing Water Levet ft 1 HEREBY CERTIFY THAT I HAVE PREPARI-D THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN W JOAQUIN COUNTY ORDINANCES, SI'ATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT.MY REQUIRED LICENSE IS CURRENT A?ID ACTIVE. WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSAT!0N LAWS. MAMI 6UM- < 'MR D' NCE NOTICE REQUIRED FQ NSP�ECToi3rn# a(-PiIAEASE CALL (20_9 I95- jf., SIGNED- TITLE DATE Uii i I I I I I Jill 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 I I I I I ' I I I I I I I I I I DEPARTMENT USE ONLY Application Accepted By �� Date IOld 4070;0 Area � �� ` Employee ID# Fn Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE Sc Received eck#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Remitted Service Reuest# 3g1 Oso Z 7 w U D 43-06 6/11/2019 WELL/PUMP PERMIT