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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -6232 (209) 468-3420 JOB ADDRESS CITYMP EAPIKE5 1 YEAR FROM LATE CROSS STREET L 1L b c,, f �'`, R 117 C AIN 0C -2 "� O " I -PARCEL SIZE �Cj t�LAND USE APPLICATION # �l OWNER NAME 1 re a � V) -CA e J PHONES V l�7 - - `Jtl��] t IL OWNER ADDRESS Jq `M CITY/STATERJP 3(,g-,7779 CONTRACTOR \j ` \ l � �i '7� d' \ A,` • n � PHONE r CONTRACTOR ADDRESS P C ,> C X CITYISTATEIDP G's I Ar ` Ar) A C1 5 V z ✓ -,C-57 PARTY: .TANT PHONE .TANT ADDRESS CITTY/STATEMP ❑ C-61 G D-09 U Other NUMBER g99-;%5 EXPIRATION DATE 7 I _ D OWNER D SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) D Arsenic (4393) INTENDED USE -Domestic/Private D Irrigation/Agriculturat ❑ Industrial ❑ Water Quality Monitoring D Soil Sampling/Characterization Public Water System If different Imm Ow ec Water System Name Contact Name or Phone Number TYPE OF WORK ''New Well Replacement Well D Weil Alteration/Modification D Other ❑ Monitoring Well(s) #of wells ❑ SoilBoring(s) #ofborngs D Geotechnical of borings Out -Of -Service Well O Out -Of -Service Well Renewal D Cross -Connection Repair WELL CONSTRUCTION Sq N Drilling Method)<,Mud Rotary D Air Rotary o Auger D Cable Toot D Push Point 0 Other Proposed Well Depth c�30 ft Excavation _I in diameter L] Open Bottom ;&Gravel Pack/Gravel Size }/ q - it 0 ConductCasing in diameter ! Conductor Casing Depth ft Well Casing Diameter - in Thickness/Gauge/ASTM Schad C I � G C t7 Steel j4Plastic 0 Stainless Steel ❑ Other Grout Seal Depth i C �' it L,, Neat Cement (94 Ib bagl5-10 gal water) )4 Sand Cement 10.3 sack mix/7 gal water D Bentonite (20% solids) ❑ Other Grout Placement Method Pumped ❑ Free Fall J Other 0 Retardant / Accelerator (name) PEDESTAL Installed By ADriller ❑ Pump Contractor u Other (Concrete Pedestal ❑Dimensions: Width --A,-ft Length __G_ftThick in ❑Christy Box ❑Stove Pipe PUMP -- Submersible❑ Turbine ❑ Other HIP '/ Pump Set It Standing Water Level ft ' "PFEBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JUiu,4614 C.Uuryii ORLAVANICa, 0 i IC Larva, mivu muLca Hrvu kEGuLjue0NS. 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. MINI. UM 443 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE 1CALL (209) f953-7697 SIGNED ;�� t' /`^"''�-dZ'^ TITLE V •Ce_ Q"S 1 rel T'vl 1 DATE V' _- PA YMFN C'�7V 23 jVEQ 4QU/N QEPgR'V34t I' N7- /DEPARTMENT USE ONLY Application Accepted By Date �47(7ri'0 Area y qll Employee ID# L),4 Grout Inspection By A JA [)at..❑ SPECIAL'A6,1Pc�ird: Pump Inspection By Data �� ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS EH043-06 6/11r2.019 a I _/ /I�,� 123,0 -� 11�75q 2_� WELL /PUMP PERMIT