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*260ep <br />Aoilta <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />1`OUN-KEFUNDABCLEE^rEE,RMIT J� WWW.SJ oy.org/eno EXPIRES 1QYEAR <br />�FROM DATE ISSUED <br />JOB ADDRESS {� 5 * fvkj�' - 4'a CfrY21Py 1 �" wky 1`� 20 / <br />CROSS STREET •• „Ob n�e�� Dr102ay0t IO,Z1ZH01� <br />APN PARCEL SIZE m/, i � LAND USE APPLICATION # <br />OWNER NAME F) :A�0✓1 'Shcov-✓� � �'L L- PHONE <br />OWNER ADDRESS I <br />),0 -S, S,erfen <br />CONTRACTOR get,` O W�an / {f"""tcor' <br />CONTRACTOR ADDRESS to ^ S*T'4 ` WA'y <br />SUBCONTRACTOR/CONSULTANT So(- <br />SUBCONTRACTOR/CONSULTANT ADDRESS ` Apf <br />LICENSE )(,C-57 ❑ C-61 D-09 Other <br />BILLING PARTY: F-1 OWNER p CONTRACTOR <br />(; ) <br />CITY/STATE/ZIP J 16r 176 t' L: L l /)Q <br />Q/ S <br />PHONE2v>-Sbyt70\ <br />CnY/STATE2IP W%, tip, `VHO <br />PHONE _ SPA- <br />%C.�I,TY/STATE2IP <br />NUMBER 00H <br />❑ SUBCONTRACTOR/CONSULTANT <br />EXPIRATION DATE 5 -3o -26V <br />DOMESTIC WELL SAMPLING: _ General Mineral/Coliform Bacteria (4391) a Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial 1 Water Quality Monitoring i( Soil Sampling/Characterization <br />Public Water System _ <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK i New Well Replacement Well I Well Alteration/Modification I Other <br />❑ Monitoring Well(s) # of wells I Soil Boring(s) # of borings �( Geotechnical q # of borings <br />❑ Out -Of -Service Well I Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump u Pump Replacement I Pump Repair ❑ Raise Well Casing <br />Drilling Method ❑ Mud Rotary C Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth �6 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 Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth K ft % Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped X Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller a Pump Contractor Other <br />Concrete Pedestal nDlmenslons: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine 4 Other HP Pump Set ft Standing Water Level ft <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 WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />IMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (20(9) 953-7697 <br />M <br />SIGNED 14V11— TITLE St4k- ve0`r163,S1r DATE V S -Z <br />Application Accepted By Date s 1 Area � �+ '` r � Employee ID# / y <br />Grout Inspection By " Date U _ SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constr cted Well Depth ft <br />i <br />COMMENTS %/('11111t/t� r I.Y)t' 4-.V- U�('rl I i- r0� -�C�L,i�^jc. a7i ;74fl✓P(1/: ;�/ <br />rn <br />a <br />m <br />D <br />0 <br />v <br />A <br />y <br />PE <br />SC Received <br />Info <br />Check#/ Amount <br />Ca Remitted <br />Permit/Codes <br />Date Service Request # Invoice # Well ID# <br />01� <br />fsc7 <br />orf I <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />