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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 J `r J-S� �-- �/'-/�� /' f CITY/ZIP , m CROSS STREET J^ APN 0(1 I J L)DO� PARCEL SIZE r�'1-1 LAND USE APPLICATION# 0 OWNER NAME PHONE J(7 I- �'�C �' y OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR �L `_'/" `S I�`L/ f / PHONE ' CONTRACTOR ADDRESS CITY/STATE/ZIP 6�a'r crz SUBCONTRACTOR/CONSULTANT T L;/ Gr'J s 6 n` PHONE V? 2 n SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP LICENSE X�'C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 127 3ZE EXPIRATION DATE BILLING PARTY: OWNER I CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING:V General Mineral/Coliform Bacteria (4391)A Dibromochloropropane(4392) Arsenic(4393) INTENDED USE KDomestic/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 ftA 1. TYPE OF WORK xNew Well Replacement Well ❑ Well Alteration/Modification ❑ Other rN ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical S E� ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair JAN 9 ew Pum E] Pump Replacement El Pump Repair ❑ Raise Well CasingJ �1► L WELL CONSTRUCTION SAN JOAQUIN SOU Drilling Method�YMud Rotary ❑ Air Rotary El Auger El Cable Tool 11 Push Point 11 Other Proposed Well Depthft Excavation L in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size eter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter"6 in Thickness/Gauge/ASTM Sched ❑ Steel .K-'Plastic ❑ Stainless Steel ❑ Other Grout Seal Dept JJ ft ❑ Neat Cement(94 lb bag/5-10 gal water) >Sand Cement�v'. sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By >ebriller ❑ Pump Contractor ❑ Other 11Concrete Pedestal[I Dimensions: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. MINIM HOU,j�ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209) 95y3-7697 SIGNED /1� TITLE DATE V U S -t- O tit t t DEPARTMENT USE ONLY ,n Application Accepted By �� G L Date /.1d bw? Area ��C Employee lb# Grout Inspection By •�. Date '1 11 SPECIAL Well Permit a Pump Inspection Bycs �.�w �4W tn+. Q.,, Date ❑ WAIVER Received .,;, Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS ExisfI, felleiovTV. To ivcjo of /on bt,7 setbeizk O'r PYIL�JjUI[�s. PE SC Received Check# Amount Date Permit/ Invoice# Well ID# Codes Info Remitted Service Request# 390 0 1 $ISS 2 L1 L. l 366 I gl�' - ft)o 2 ;:AP0CI410 L)99 ) 150 i L L- Pio l v L3ga 3 70 Zllc 211w I EHD 43-06 6/11/2019 WELL/PUMP PERMIT