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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 1'4v1wRtrurvuH0Lt rtrcml I / , WWW.sjgov.org/ena EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS !x'93y1rUL, n n CITY/ZIP SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP LICENSE 0140-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 3 7 %39s EXPIRATION DATE BILLING PARTY: ❑ OWNER >&ONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) PA J_% AdIlZal INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characteriz cce'� ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number r „ TYPE OF WORK 49$4ew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other " 4UCL ❑ Monitoring Wells) # of wells ❑ Soil Boring(s) # of borings ❑ GeotechnicalE�yVIN C N; ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair HEALTH EPAENTAL ON flew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing DEPARTMEN' WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation I1_ in diameter ❑ Open Bottom SeGravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched2Z ❑ Steel Wlastic ❑ Stainless Steel ❑ Other Grout Seal Depth / 13 a ft ❑ Neat Cement (94 lb bag/5-10 gal water) 'Sand Cement0� _sack mix/7 gal water ❑ Bentonite (20% solids) ❑ Other Grout Placement Method `.'Pumped ❑ Free Fall ❑ Other ❑ Retardant /Accelerator (name) PEDESTAL Installed By driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions: Widthft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP . 4ubmersible❑ 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. MINIMUMA8 HOUR AAPVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-/7697 SIGNED (/ /L TITLE IwJ DATE 7 -'lo --L,' DEPARTMENT USE ONLYql /� t� Application Accepted By `-� Date 71101d awn Area q�I Employee[D# �!� Grout Inspection By a 9)le (aorL:a. %W.'L Date 5lo-M,El SPECIAL Well Permit Pump Inspection By Date 3 ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS FY►st%TwWe�) �o Se1VP eX�sllnc, /Ps►G�PN�F I� JCI delve hPy1 reg+<.�ente 't;' p )3 40 D CROSS STREET/,' [� G/ APN PARCEL SIZE LAND USE APPLICATION # OWNER NAME C UO 0OL/ PHONE 993-3997. OWNER ADDRESS / CITY/STATE/ZIP G'6)/✓ 1 / CONTRACTOR /V j2acs % v /" (j PHONE 3yyy�� 7 - ^7 ` yZs CONTRACTOR ADDRESS VJV[ -/�s,J CITY/STATE/ZIP 4�/(J�-�^7y r SUBCONTRACTOR/CONSULTANT Q A / �,1 c,3rWZ � '"'%� PHONE � '1 7 J ! W SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP LICENSE 0140-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 3 7 %39s EXPIRATION DATE BILLING PARTY: ❑ OWNER >&ONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) PA J_% AdIlZal INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characteriz cce'� ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number r „ TYPE OF WORK 49$4ew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other " 4UCL ❑ Monitoring Wells) # of wells ❑ Soil Boring(s) # of borings ❑ GeotechnicalE�yVIN C N; ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair HEALTH EPAENTAL ON flew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing DEPARTMEN' WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation I1_ in diameter ❑ Open Bottom SeGravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched2Z ❑ Steel Wlastic ❑ Stainless Steel ❑ Other Grout Seal Depth / 13 a ft ❑ Neat Cement (94 lb bag/5-10 gal water) 'Sand Cement0� _sack mix/7 gal water ❑ Bentonite (20% solids) ❑ Other Grout Placement Method `.'Pumped ❑ Free Fall ❑ Other ❑ Retardant /Accelerator (name) PEDESTAL Installed By driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions: Widthft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP . 4ubmersible❑ 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. MINIMUMA8 HOUR AAPVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-/7697 SIGNED (/ /L TITLE IwJ DATE 7 -'lo --L,' DEPARTMENT USE ONLYql /� t� Application Accepted By `-� Date 71101d awn Area q�I Employee[D# �!� Grout Inspection By a 9)le (aorL:a. %W.'L Date 5lo-M,El SPECIAL Well Permit Pump Inspection By Date 3 ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS FY►st%TwWe�) �o Se1VP eX�sllnc, /Ps►G�PN�F I� JCI delve hPy1 reg+<.�ente EHD 43-06 6/11/2019 WELL/PUMP PERMIT Permitl Service Requestl- Ir.K�.4+WO•VISM ars EHD 43-06 6/11/2019 WELL/PUMP PERMIT