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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 NON-REFUNDABLE [[PEE�R/MI(T� / www.sigov.org/ehd �} ( EXPIRES 1 YEAR FROM DATE ISSUED JOBAODRESS y(J I"1 Qpp�Vy. r�\Ct�i��i(`)` ,�P. �j�ICII �. Lct j Cn rZI}P 7�\C6,tnQ ) �+C?(�'+.�•X CROSS STREET b 1 1 l'[' h.V APN 00540001 0 PARCEL SIZE Vr ��tt /i LAND USE AJPPUCATIONN# o OWNER NAME �1 r"1 G'VYIj Z PHONE OWNER ADDRESS CITYISTATE/Z1P CONTRACTOR 1 f e!` 1`�f ', 1�^�^ / PHONE 3(,c) -2 7 / 9 } CONTRACTOR ADDRESS U T7�) 'l .�/ C /s—T% V�I 1�-) C A �i G SUBCONTRACTOR/CONSULTANT f PHONE t SUBCONTRACTORICONSULTANT ADDRESS CITYISTATE/ZIP LICENSE )(C-57 ❑C-61 ❑D-09 ❑Other NUMBER 2q9 3 b 3 ExPIRAnoN DATE 7-.7 ' BILLING PARTY: ❑OWNER ,CONTRACTOR 0 SUBCONTRAcrORICONSULTANT ell DOMESTIC WELL SAMPLING:X General Mineral/Coliform Bacteria(4391)XDibromochloropropane(4392)❑Arsenic(4393) INTENDED USE A DomestictPrivate ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring 0 Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK XNeW Well ❑Replacement Well D Well Alteration/Modification ❑Other — 0 Monitoring Well(s) 71 of wells ❑Soil Boring(s) #of b°dngs 0 Geotechnical #of bcdngs ❑Out-Of-Service Well D Out-Of-Service Well Renewal ❑Cross-Connection Repair New Pum ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing WELL CONSTRUCTION Drilling Method A Mud Rotary 0 Air Rotary ❑Auger 0 Cable Tool ❑Push Point D Other Proposed Well Depth :2,4i It Excavation in diameter ❑Open Bottom X Gravel Pack/Gravel Size!_in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched C.l 7(y^ ❑Steel Plastic ❑Stainless Steel ❑Other Grout Seal Depth 1(',0 ft 11 Neat Cement(94 lb bag/5-10 gal water Sand Cement (n sack mixf7 gal water ❑Bentonite(20%solids) ❑Other Grout Placement Method_*Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed ByPedesDriller ❑Pump Contractor D Other 1g Concrete tal❑Dimensions:Width_L_ft Length ft Thick in ❑Christy Box n Stove Pipe PUMP `'L4 Submersible❑Turbine ❑Other HP -3 Pump Set q 3i ft Standing Water Level 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. ibs:9W'o3d�eoi(-iOU fal3�'l1°.MCE •#tl'Y�C € Ee"h+9 —r: i INSPECTIONS-`oP tytQ.�s CALL 009)'35"3,7C1v7 SIGNED_ /. �CL�i.2.1./-r✓� TITLE \l CC t�ir'C S i r4 e 04 DATE 4 i 5 1 Q4 U I e- �.. 17 I IL RFS MENT OR10, 4?p 20?0 SRO�l N C N o pAR N ry T DEPARTMENT USE ONLY Application Accepted By Cesar Ruvalcab Date 4/20/2020 Area 4/95 Employee ID# SK Grout Inspection By ! Date S/1'i Z ❑ SPECIAL Well Permit: Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE Sc Received Check#/ Amount Date Perm! Invoice# Well ID# Codes Info B Cash r Remitted Service Request 4391 ?1 $145 4392 $70 4366 180 $420 P0040 40 4380 $152 WP0040741 EHD 43-06 6/11/2018 n /`^ �/ 2- l.� WELL/PUMP PERMIT