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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 PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR�FROM DATE ISSUED ' JOB ADDRESS I I I`"I ' �,n••} 1` D• CITYZP A CcI A 00 t v}l CJ,3`?V m i'� CROSS STREET 1�/ T I r) SD APN 01;1 y I qa •1 PARCEL SIzE _LAND USE APPLICATION X o OWNER NAME C^ f)' F'i^n c) Ge)b c1i ) /^ PHONE •^/ L,,F OWNER ADDRESS \F� / �I_{''�-1 t T�'` \-� CMISTATEMP LLc 1 I CN Z9 5'^ -./y CONTRACTOR `J CO)L'Y 'p7�D f' )'I n� (PHONE 3�-•1'�•1 3`(�],�l_I�-,a 779 CONTRACTORADDRESS P-O ' Li G/` —1 CITY/S..fDP `7 tl l�, C A —1 5 0 SUBCONTRACTOR/CONSULTANT PHONE SUBCONTRACTOR)CONSULTANT ADDRESS CITYYIISTTATE/(7�JP LICENSE )kG57 )<C-61 0 D-09 0 Other NUMBER � I ISO 3 EXPIRATION DATE 7—✓z ) BILLING PARTY: 0 OWNER >kCONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) INTENDED U5F Domest c:/Private 0 Inigabon/Agricultural 0 Industnel 0 Water Quality Monitoring C Soil Sampling/Characterization u Public Water System Rditreremtram Owner. Water System Name Carded Nsme or Phone Number TYPE OF WORK )(NewWeB D Replacement Well 0 Well Alteraliorl/Modification n Other 0 Monitoring Well(s) #of wells D Sal Boring(s) A of borings D Geotechnical #of boriner l7 Out-Of-Service Well 0 Out-Ol-Service Well Renewal Ll Cross-Connection Repair New Pump 0 Pump Replacement C Pump Repair D Raise Well Casing WELL CONSTRUCTION Drilling Method>-(Mud Rotary 0 Aur Rotary 0 Auger D Cable Tool D Push Point ❑ Other Proposed Well Depth . [) it Excavation I in diameter C Open Bottom X Gravel Pack/Gravel Size /4_ in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter 'n Thickness/Gauge/ASTM Sched L C SteeliPlas6c ❑Stainless Steel G Other Grout Seal Depth ❑Neat Cement(94 Ib bag15-10 gat water) ❑Sand Cement sack mix/7 gal water ❑Bentonite(20%solids) D Other Grout Placement Method 0 Pumped 0 Free Fall D Other 0 Retardant/Accelerator(name) PEDESTAL Installed By Driller 0 Pump Contractor C Other Concrete edestal eDimenslons:Width__4_ft Length it Thick in D Christy Box D Stove Pipe PUMP Submersible[I Turbine C Other. HP Pump Set 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, &tiddi UM 48 HOUR ADVA.-4CE NOTICE,ZE IUIRED FOR 44SPECTIONS •PLEASE CALL 1209)963-71:'9- SIGNED l Jf ''L/ ^ TITLE. V%C_e- Y` C-S IC cni DATE �`1T R gyil� NT Sep 01? F® oFAMRT o c v�Y ZZ MFNT r DEPARTMENTUSEONLY Application Accepted By ��` Date Area y ��i Employee,D# F Grout Inspection ByDate ft G SPECIAL Well Permit L FT Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth COMMENTS S('C:2i?L ( !a^?PS C s)P.. L'XISfr`r'!( .J:)1 !PiN,:.r%I IV1 t.•':.1�. PE SC Received Check#/ Amount Detect Permit/ Invoice# Well IN Info CGS Remitted Service Re es X y3E•o ,Dsa i� I - H EHD 43-06 6/11/2019 WELL/PUMP PERMIT