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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 IVVIN-I[tFUNUA131-t rtKMII EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS j�JL L J 1:7 7 [/�7� f07✓ CITY/ZIP "Y Ci/13'Y+/I( CROSS STREET !� �1' �APN6L / — y S'y/PARCEL SIZE a LAND USE APPLICATION # OWNER NAMEL//�r�� `"� PHONE / y OWNER ADDRESS 3A en k CITY/STATE/ZIP (/-7 CONTRACTOR /'Y d-� (3 ie�-7C� lLl%s�(�C l"I PHONE „��Y�r CONTRACTOR ADDRESS /y %j" L/??CITY/STATE/ZIP /✓� � ✓✓talo -r SUBCONTRACTOR/CONSULTANT ��% C� I"" PHONE 7y.5- 2-,0 V,t- SUBCONTRACTOR)CONSULTANT ADDRESS LICENSE --I!!C-57 ❑ C-61 ❑ D-09 ❑ Other BILLING PARTY: OWNER CONTRACTOR (CITY/STATE/ZIP NUMBER SUBCONTRACTOR/CONSULTANT EXPIRATION DATE r97� .2,/ DOMESTIC WELL SAMPLING:D( General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) - Arsenic (4393) INTENDED USE ,'Domestic/Private ❑ Irrigation/Agricultural ❑ 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 4 Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings Li Geotechnical # of borings 11 Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casino Drilling Method Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth �7 ft Excavation !r 2, in diameter ❑ Open Bottom XGravel Pack/Gravel Size in diameter ❑ Conduct Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched 2--&0 ❑ Steel <Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ) ft ❑ Neat Cement (94 Ib bag/5-10 gal water) Sand Cement 10,3 sack mix/7 gal water ❑ Bentonite (20% solids) ❑ Other Grout Placement Method XPumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By -Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions: Width ' ft Length .i ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP v<Submersibleo Turbine ❑ Other HP 1� 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. MINI �U,iM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) ,9/53-7697 9 / SIGNED ..li�L76 -A-.- TITLE i�'I✓CJ�' ' DATE T L7- L T m n v v m m N y Z— DEPARTMENT U E ONLY r Application Accepted By L/ Z/ Date -� Area L� Employee ID# I� K Grout Inspection By �!r.iA(�c�� Q.. � af" 2 Date G(JI?D21 ❑ SPECIAL Well Permit Pump Inspection By Date l zl' 71-o ❑ WAIVER Received Soil Boring Insp c' n By DateConstructed Well Dep h _ COMMENTS '� rDi i --C C i l Gl/� L �-1 "✓`^D LtJb vCi SE'GOk7 PE Codes SC Received Info By Check#/ CPSIh. Amount Remitted Date I I Permit/ Invoice # Well ID# Service Request # i. 3 g e s 5 ,'�- 3A6 18'0 y a b 5 (0 11 N3ct) cl to .-70 �� r EHD 43-06 6/11/2019 WELL /PUMP PERMIT