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N�Q�510w WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 NUN-KEFUNDABLE PERMIT JOB ADDRESS 31-.ito 0%.51e f CROSS STREET A to `t' N' -LC\ > OWNER NAME OWNER ADDRESS WWW.SJgoy.Org/ena tAPIKhb 7 YEAR FROM DATE ISSUED CITY/ZIP 1� MCy ()♦� ��✓� APN t 1054 Ll PARCEL SIZE i "LAND USE APPLICATION # PHONE CITY/STATE/ZIP CONTRACTOR Nb1 ID I t t L'4i( ,ccr) i.Gi`h e.n j PHONE 1) �I }-IG CONTRACTOR ADDRESS + ^WlASt 1'�\ Wt -f 1l�L CITY/STATE2IP L-�y LSI i5 `A� SUBCONTRACTOR/CONSULTANT 12 'Z '. PHONE —� SUBCONTRACTOR/CONSULTANT ADDRESS LICENSE �k C-57 C-61 BILLING PARTY: I i OWNER D-09 ❑ Other F1 CONTRACTOR CITY/S T A TE/ZIP NUMBER L��FU4 1 SUBCONTRACTOR/CONSULTANT EXPIRATION DATE DOMESTIC WELL SAMPLING: J General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) NTENDED USE ❑ Domestic/Private Irrigation/Agricultural I 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 J New Well Replacement Well ❑ Well Alteration/Modification Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings X Geotechnical # of borings ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair ! ! New Pump CI Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method )(Mud Rotary C Air Rotary ?� Auger Cable Tool Push Point ❑ Other Proposed Well Depth •10 i 50 ft Excavation 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 Sched Steel Plastic Stainless Steel ❑ Other Grout Seal Depth ft Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water Bentonite (20% solids) Other Grout Placement Method Pumped Free Fall ;Other 1.4-Y.rv` • P Retardant / Accelerator (name) PEDESTAL Installed By Driller Pump Contractor Other Concrete Pedestal i IDimenslons: Width ft Length ft Thick in Christy Box Stove Pipe PUMP Submersible Turbine - 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. vMINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR �}INSPECTIONS - PLEASE CALL (209) 953-769]7 SIGNED rhey TRLE �t'l4 �r,Jioc)'`,T DATE EF'ARTMEN7 USE NLY Application Accepted By - i Date �(�� % Z-( Grout Inspection By Date 12 'Z '. Pump Inspection By Date Soil Boring Inspection By Date// COMMENTS , q ri �e' u)( 6 p, ,�1�' ��j I `y`'ily!,rt Z Area Employee ID#�"A---� ❑ PECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft a Uo✓1 c' ro� ;i � c N 7Ib ")) a o, n W4,4f� U Y Y i h 6 P rt3aF ayu,"iLj PE SC Received Check#/ Codes Info C Amount Date Permit/Invoice # Well ID# Remitted Service Request # y2%2 .s'c6'1L; - i EHD43-06 6/11/2019 WELL /PUMP PERMIT 30M I fl olxr-im.