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a �E��- p✓~ - y�P Wog- �.vt ti l G!/k,L/C._ WELL/PUMP PERMIT /°�5- �h �` �" ' ('a�Wv-t'L t SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 NON-REFUNDAB)_E PERMIT www.siqov.org/ehd EXPIRF.S 1 YEAR FROM DATE ISSUED JOB ADDRESS 1117Dl CITY/Zip m �J� D CROSS STREET APN v�� PARCEL SIZE 2— LAND USE APPLICATION# o OWNER NAME PHO �N �}N� OWNER ADDRESS r�e�h CITY/$TATE/Z1P—L/'�I L , G1 CONTRACTOR bnR UY I FHOONE ; -1 / DI D4 CONTRACTOR ADDRESS CITY/STATE2IP Vr11'Yr�l 1A,ITnW4/�l R SUBCONTRACTOR/CONSULTANT V _ ' L-A PHONE SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STA P ^� LICENSE XC-57 I I C-61 i 1 D-09 I I Other NUMBER J�EXPIRATION DATE t� BILLING PARTY: L OWNER CONTRACTOR L SUBCONTRACTOR/CONSULTANT DoMEsnc WELL SAMPLING:-i General Mineral/Coliform Bacteria(4391)':J Dibromochloropropane(4392)t]Arsenic(4393) INTENDED USE Domestic/Private 1.Irrigation/Agricuftural r-Industrial Water Quality Monitoring -1 Soil Sampling/Characterization Public Water System If dflerem from Owner: Water System Name Conrad Name or Phone Number TYPE OF WORK XNew Well C Replacement Well ['Well Alteration/Modification ❑Other Monitoring Well(s) #of wells F Soil Boring(s) a of borings Geotechnical #of borings Out-Of-Service Well Out-Of-Service Well Renewal ❑Cross-Connection Repair u New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing WELL CONSTRUCTION Drilling Method Mud Rota Air Rotary Auger Cable Tool -:Push Point - Other Proposed Well Depth ft Excavation. in diameter 1_I Open Bottom A Gravel Pack/Gravel Size In diameter I COndu r Casing in diameter / Con�uycytn�r sing Depth ft Well Casing Diameter In Thickness/Gauge/ASTM Sch- ` Steel ffCPlastic Stainless Steel - Other Grout Seal Depth ft C Neat Cement(94 Ib bag/5-10 gal water) C Sand Cement sack mixn gal water Bentonite(20%solids) n Other Grout Placement Method XPumpecl �i Free Fall Other F. Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller c Pump Contractor E Other ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in 7 Christy Box .I Stove Pipe PUMP C Submersible❑Turbine L: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 COMPE A N LAWS. MINIMU 4 R V E NOTICE REQUIRED FOI} IINSPE (TcI.(AA/NS--PLEASE CALL(209 951-7119 SIGNED TITLE i )V �l `'r DATE-1 bu EC MEN T EI VF p AY 2 y 2021 gQUIN C l DE ARTMENTy A MENT U E ONLY [%J /i��//�Jy�� Application Accepted By Date Area / ` T Employee ID#jq j �'�'7 Grout Inspection By Date SPECIAL Well Permit Pump Inspection By Date WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#I Amount Da Permit/ # Well ID# Co I fo B Cash Remitted a a ice Request# EHD 43.06 6/112019 lzsz!7�2� WELL/PUMP PERMIT � I ; .