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~, WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT <br />www.sjgov.org/ena <br />1_AYI11tJ 7 TEAR FROM DATE ISSUED <br />JOB ADDRESS <br />J I S <br />J Q <br />I V • " 1112.0'1 <br />Crrv21P � 1 a �'1 95'366 <br />CROSS STREET (� <br />/ <br />I y' I^�' �� <br />. / ) /- <br />5 A, VC APN z^C� �1y0 -y PARCEL SIZE � LAND USE APPLICCAITION # <br />OWNER NAME <br />%L�S��� <br />I I.✓� �I S �/9\ <br />e� <br />PHONE Z0 `- c) -I - 2L '33 <br />OWNER ADDRESS <br />^�Qf fie) <br />J- 1 0'?--, <br />1� <br />I l �%T` t �1` v` 1� un a <br />CITY/STATE/LP Mu C (e c, j o if �'1 61 7 3 5 C7 <br />CONTRACTOR <br />L-✓, <br />.J �1 S 1 ,ff <br />PHONE 21U of - `J 2 cf - " I I V <br />UU <br />CONTRACTOR ADDRESS 1 D 2 J Z' > C r1 I I V CA <br />CITY/STATEMP k4i Q a e y,,Lx i CA I S 5S -I <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />IOC -57 IS, C-61 ❑ D-09 ❑ Other <br />PARTY: ❑ OWNER IICONTI <br />CITY/STATE/LP''_ <br />NUMBER b YQ <br />❑ SUBCONTRACTOR/CONSULTANT <br />PHONE <br />EXPIRATION DATE q- 30 - ab'Q20 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) 7 Arsenic (4393) <br />INTENDED USE X Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well U. Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />F1 New Pumo n Pumo ReDiacement X Pumo Reoair ❑ Raise Well Casino <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller APump Contractor 1❑ Other <br />�LConcrete Pedestal ❑Dimensions: Width S ft Lenoth ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP XSubmersiblell Turbine ❑ Other HP —J-- Pump Set_(. V ft Standing Water Level !;� ft <br />r <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WJTH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. i <br />REQUIRED <br />SIGNED <br />CALL (2091953 - <br />WENT <br />CEIVED <br />P 2 1 2021 <br />JOAQUIN COUNTY <br />VVIRONMENTAL <br />LTH DEPARTMENT <br />DEF�ARTMENT�SEONLApplication Accepted B II Date,p` Area Employee ID#�%'I <br />Grout Inspection B Date ❑Well Permit <br />P I <br />Pump Inspection By ate C), �y-1 L� ` ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS t aCk `� 3 2 �n i. Q�IA <br />EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />