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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 NUN-KEFUNDABLE PERMIT www.sjgov.org/ehd yEXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 1,951 C(lb/wt S G" e4- CITY/ZIP S7 SOL &„ 9S -0 z� CROSS STREET C/Owes A',1 V_lee � AP�N/1 /0 V16 040 PARCEL SIZE Z' z LAND USE APPLICATION # OWNER NAME k,-xsAr[lL 1VI+/�ts /�lG1rL'�1 ��St Lot L[( PHONE 17o9,3Z/- f3p/79\ OWNER ADDRESS I3(-' 1 so 11 )rl(,, ! f %y L'p. CITY/STATE/ZIPS 'V' E,I' (6c,) rl9 Dl CONTRACTOR fru k PHONE CONTRACTOR ADDRESS 276 Y Bee."' o IMA i CITY/STATE/ZIP SUBCONTRACTOR/CONSULTANTVV GS COICb ((77 1�1�P1� �G► �JO� �N G PHONE 20q/ - SUBCONTRACTOR/CONSULTANT ADDRESS �� /JOX x,33 CITY/STATE/ZIP Ecce /y+ + (4 ?C -3,'O LICENSE (C-57 Ell/ / C-61 ❑ D-09 ❑ Other NUMBER D -7G EXPIRATIONDATE /3//70n, BILLING PARTY: ❑ OWNER ❑ CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391), Dibromochloropropane (4392) Arsenic (4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural C Industrial `I Water Quality Monitoring X Soil Sampling/Characterization Public Water System Wil/ L'm gn - y.. -ii "6215 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) X 6 # of borings Geotechnical # of borings ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal Cross -Connection Repair L New rump i_! rump meplacemenr u WELL CONSTRUCTION L Kalse vven La Drilling Method ❑ Mud Rotary ❑ Air Rotary I j Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth /� ft Excavation in diameter u Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched iI Steel = Plastic C Stainless Steel i I Other Grout Seal Depth /S ft X Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water Bentonite (20% solids) 1 Other Grout Placement Method :1 Pumped ❑ Free Fall Y Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor 11 Other ❑ Concrete Pedestal 0 Dimensions: Width ft Length ft Thick in Christy Box ❑ Stove Pipe PUMP ❑ Submersible Li Turbine I 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. MINIM�J74 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS CALL (209) 9/53-7 97 SIGNED i /� � TITLE Lw_lLCCI�/+�c-W /CGyil/G/2H DATE s 17 7i� DEPARTMENT USE ONLY Application Accepted By Z'_' -Z_ Date Grout Inspection By Pump Inspection By �� Soil Boring Inspection By _A COMMENTS Date Date Date ,ten <' Area d $ k nEmployee ID# / SPECIAL Well Permit WAIVER Received Constructed Well Depth ft T m D 0 0 m CA PE Codes SC Received Info Check#/ Amount Date as Remitted Permit/ Invoice # Well ID# Service Request # L)3 1a 1�5_ 0 i? ,j V"l EHD 43-06 6/11/2019 WELL/PUMP PERMIT