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Z 30 • WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 • NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS asd Ay'Q_ CITY/ZIP .K OA �✓ V r�ir CROSS STREET C.O(e/lOr�0..t(t7 AVC,—q. APNN X63-0 V—110 PARCEL SIZE 0.6.LAND USE APPLICATION# A OWNER NAME (.7I CWJC/1 .�' iA n�/OCU/l..rnG../, A.1LrA4 �1 PHONE �41A n�/� rNa, OWNER ADDRESS t'u-1 J G.I L/enE.00O 5111 QI 10 13 CITY/STATE/ZIP 51644n 44 `7.M.O3 CONTRACTOR V W 'DrlfijnA,j -I PHONE CONTRACTOR ADDRESS_ //33 I3&I A td - /'� CITY/STATE/ZIP l .Jf CA 95/6n 32 SUBCONTRACTOR/CONSULTANT WIJL P -KUW +ASof."Jy-s ( PHONE(q 16))`3r2-1'13q SUBCONTRACT/OR/CONSULTANT ADDRESS ;O50�&J f X71 31yot CITY/STATE/ZIP 1A/CS/ 1'�� 6�t 95/6 +I 51' n' LICENSE C-57 D C-61 ❑D-09 ❑Other NUMB � ER T2090y EXPIRATION DATE BILLING PARTY: ❑OWNER ❑CONTRACTOR VSUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)0 Arsenic(4393) INTENDED USE ❑Domestic/Pdvate D Inigation/Agricultural D Industrial ❑Water Quality Monitoring Soil Sampling/Characterization ❑Public Water System 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 Bodng(s) #ofbodngs N(Geotechnical 12 4ofborings ❑Out-Of-Service Well D Out-Of-Service Well Renewal D Cross-Connection Repair Ly ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing WELL CONSTRUCTION Drilling Method D Mud Rotary 0 Air Rotary Auger ❑Cable Tool D Push Point ❑ Other Proposed Well Depth J5'30 It Excavation IC-K in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_in Thickness/Gauge/ASTM Schad ❑Steel D Plastic ❑Stainless Steel ❑Other Grout Seal Depth IS-50 ft VNeat Cement(94 Ib bagl5-10 gal watef) D Sand Cement sack mixfl gal water ❑Bentonite(20%solids) D Other Grout Placement Method ❑Pumped `Free Fall ❑Otherrieive r+�eJ-a ar a$ c lerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other D Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible❑Turbine ❑Other HP Pump Set It 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. MINIMUM 4,88 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209))953-76/97 SIGNED s /}2]`/"�'t TITLE__ ,J/<.�/ �.N i.�L¢vJ- DATE YMENT CE9VE® 0 202', Slow N AQUIN COUNTY 7JEWRONMENTAL PFVN DEPARTMENT (' DEPARTMENT USE ONLY �} Application Accepted ByDate 7 Area Employee ID# Gr Lit Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft CO,WENTS-rirg,ns Arf nc From W Poo149o83 atmC W PODH off I YPY►1mie proe. bv- vz r f t./aepyr *h4►'1 o3c) Cbel- t. 1t�uY>( of C'/ /S enlnuo ma. PE SC Received Check#/ Amount at Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service eq uest 37.E s o /1 10 0 00 25. 31 EHD 43-06 6/11f2019 �6T 6,�" � n C!;ZPERf y