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J WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -6232 (209) 46B-3420 NON-REFUNDABLE PERMIT// � / www,sjgov.org/ehd EXPIRES 1 YE �rJJAR FROM DATE ISSUED JOB ADDRESS dti� ` y4P (a Oe•"_ Y� AG/C� - CITY/ZIP �f/W�N, c`m E � ,� . 9s3.za-S6is CROSS STREET � � I ONE IIZ ApN oq`/9 �dwi-3Ga-oDpRCEL SIZE /, r LAND USE APPLICA '�J TIONG# A OWNER NAME `\a�,Jr^� Ar= -Q % Dr ay"E ✓A S PHO�N.ta�% OWNER ADDRESS o7n75/y Stwo? r(�Ff' �Qd, CITY/STATE/ZIP CONTRACTOR CA-rvE?p[rt/-.`' J O^J 1 i NC ` pHONIro0��%f CONTRACTOR ADDRESS J�JO T �y� •t Cr T� CITY/$TATE/ZIP �O Np"Q�v _,& 9r37o SUBCONTRACTOR/CONSUL7ANT SUBCONTRACTOR/CONSULTANT ADDRESS LICENSE ''d C-57 fl C-61 r D-09 D Other BILLING PARTY: U OWNER U CONTRACTOR PHONE CITY/5TATE2IP NUMBER �.,r� 57 ,� EXPIRATION DATE 7 3 � /Z O L SUBCONTRACTORICONSULTANT DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) C Dibromochloropropane (4392) ❑Arsenic (4393) Owner: Water System Name Contact Name or Phone Number Mud Rotary C Air Rotary 7 Auger ❑Cable Tool C Push Point C Other Pro osed Well p INTENDED USE ❑ Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑ Soll Sampling/Characterization D Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK (New Well D Replacement Well ❑ Monitoring Wells) # of wells ❑ Out -Of -Service Well f1 New Pumn fl Pumn RenlanemenT ❑ Well Alteration/Modification ❑Other ❑ Soil Borings) #ofbodnga ❑Geotechnical ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair -1 Pumn Renair r Raim V1/all r:acinn # of borings WELL CONSTRUCTION Drilling Method Mud Rotary C Air Rotary 7 Auger ❑Cable Tool C Push Point C Other Pro osed Well p De th �� p �_ft Excavation In diameter C Open Bottom � Gravel PacWGravel Size in diameter i I Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched.$D G 7 Steel Plastic ❑Stainless Steel ❑Other Grout Seal Depth�ft n Neat Cement (9416 bag/5-10 gal wafer) � Sand Cement sack mixl7 gal water Bentonite (20% solids) C Other Grout Placement ethod umped C Free Fall ❑Other C Retardant I Accelerator (name) PEDESTAL Installed ey ❑Driller ❑Pump Contractor 7 Other u Concrete Pedestal uDimensions: Width ft Length ft Thick in L Christy Box L Stove Pipe PUMP I I Submersible I Turbine I Other HP Pump Set 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. MINI M 48 OU�GE NOTIGE REQUIRED FOR�NSPEG�ITIONS -PLEASE CALL (209) 953-7y697 SIGNED �� TITLE /�Ef � ✓'ENT DATE �}-/�rr /f Application Accepted Byr Grout Inspection By Pump Inspection By. Soil Boring Inspection By COMMENTS ;A TMENT US O Y ate � /� Date Date Date PAYMENY RECEIVED DEC 1 9 2019 N JOAQUIN COUNTY ENVIRONMENTAL ALTH DEPARTMENT Area �� Employee ID# 't��F1[�1 ❑ SPECIAL W211 Permit ❑ WAIVER Received Constructed Well Depth yoO ft EHD •�:!err.�r�-r,�►��:�as��m►��rm��r�� i►�rn■��r:1r�—�r.>ir�m.��r��c i..,rr� 43-06 6/11/2019 WELL/PUMP PERMIT