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SAN JoAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 NON-REFUNDABLE PERMIT 2 WWW.sjgov.orglehd EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS a!515 S-eletein Rid CROSS STREET ton e CY! k APN a l4S-C2 5-0 a g PARCEL SIZE i' <,- LAND USE APPLICATION # OWNER NAME A felon do',4 C e-1 i Ca 6 ILtdc, CITY/STA rzip ES cE0 )PH (-,.._ els-12x) OWNER ADDRESS @ 15 i 6 )-eytb ri 124 ON; CONTRACTOR -1" : 1 - Lc V eli piA nip 5 ill C.. CONTRACTOR ADDRESS 5.09 pHoNEDa ao(9,9 77411j khn pi CITY !sr A-maim-to Co 9 0 c),-- SUBCONTRACTOR/CONSULTANT ki )14 IONE IV I 4- 5350 i v ifi tPt SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP LICENSE _ C-57 1C-61 _ D-09 U Other 1921 NUMBER X7 (9 (APO EXPIRATION DATE ird 1 31 1 2 2 BILLING PARTY: OWNER (CONTRACTOR i SUBCONTRACTOR/CONSULTANT CIT 01 53 Water System Name INTENDED USE Domestic/Private u Irrigation/Agricultural _ Industrial _ Water Quality Monitoring _ Soil Sampling/Characterization _ Public Water System If different from Owner: Geotechnical # of borings Li Cross-Connection Repair TYPE OF WORK New Well Li Replacement Well u Well Alteration/Modification J Other - Monitoring Well(s) # of wells n Soil Boring(s) # of borings _ Out-Of-Service Well u Out-Of-Service Well Renewal 1 New Pump I] Pump Replacement dPum. Re air 0 Raise Well Casin Well Casing Diameter Grout Seal Depth in Thickness/Gauge/ASTM Sched _I Steel LI Plastic _ Stainless Steel Li Other ft 7 Neat Cement (94/b bag/5-10 gal water) 17 Sand Cement sack mix/7 gal water in diameter in diameter J Open Bottom L Gravel Pack/Gravel Size WELL CONSTRUCTION Drilling Method _ Mud Rotary Li Air Rotary Li Auger _ Cable Tool L Push Point _ Other Proposed Well Depth ft Excavation _ Conductor Casing in diameter / Conductor Casing Depth 1 Bentonite (20% solids) I Other Grout Placement Method - Pumped 17 Free Fall 11 Other n Retardant / Accelerator (name) PEDESTAL Installed By 7 Driller 0 Pump Contractor L Other _ Concrete Pedestal uDimensions: Width ft Length ft Thick in _ Christy Box u Stove Pi ,e PUMP Submersible Turbine 7 Other HP 5 Pump Set ft Standing Water Level -ft ft Contact Name or Phone Number c730 7-1 WELL/PUMP PERMIT DOMESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (4391) ii Dibromochloropropane (4392) D Arsenic (4393) MI IM 4 „Ad =11111MMIME • 1•111•1=1•1111111111 111111111111111111 I ,11111111111111111111111 Iliiiiii iiiiiillE111111111111011111111111111 110111111111•11M11•11111111 1111•111111INEMEIIIMINUMpilINIIIIIPIIM11111111MINIELOIER1111.1 NIIIIIIIINMIIIIIIMINIEMiti111111ElatilliorMillow•grim 1111111111•111111111MEMINIENE .4.: .241moio OMR NNE p_gifiRm__I IIIIIMIIIMEMMINONERNEMINENEEMOW Ems sominisomy 11111•1111111MMEINEEMINSEMOMINIMMEILIM IflIUhIUIUIIIiIjjjjjjUIIiFIUIUU _EIREPIMIN4 EMENMEMEENNEEMENEEMENEMENMENNEMEMiligige/ 0 ••••••••••••••l•• 1 1 I 1 I 1 1 1 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 HEREBY C RTIFY 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 WIT THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKE ENSATION L W . M 48 HOU '1ADVANCE ICE REQUIRED FO INSPECTIONS - PLEASE CALL (2u9) 9.4.377 SIGNED KIZ —41.10 -i•ITLE &Mail DATE DEPARTMENT USE ONLY Application Accepted By Date ilgQE/d Grout Inspection By Date Pump Inspection By cv‘,Lt% ki Z. Date I Soil Boring Inspection By COMMENTS Date Area Employee ID# SPECIAL Well Permit 1 WAIVER Received Constructed Well Depth ft PE Codes SC Info Received ,Ry Qle- alec.aldi Amount Remitted Date Permit/ Service Request # Invoice # Well ID# 43ie. os-o 45-- 3/ il2 0 4-7) II-19-1 RIFOOttiVai EHD 43-06 6/11/2019 WELL /PUMP PERMIT