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WELL/PUMP PERMIT ' v `J SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-623 ( ., J�' NON-REFUNDABLE PERMIT www.sjgov.org/ehd XPIRES 'I YEAR FROM DATE ISSUED rn JOB ADDRESSiz), CITY/ZIP � D CROSS,SjREET APN " ? 42/PARCEL SIZE' LAND USE APPLICATION# p ail �AJ OWN R NAME OWNER ADDRESS ]' J CITY/STATE/ZI /69 95a CONTRACTOR PHONE a?oq qN- �( CONTRACTOR ADDRESS D _ 1 CITY/STATE/Zi ♦J��C�S SUBCONTRACTOR/CONSULTANTJ /n PHONE SUBCONTRACTOR/CONSULTANT ADDRESS C1 /STATE/ZIP n} LICENSE VC-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE / V BILLING PARTY: ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTORICONSULTANT DOMESTIC WELL SAMPLING:n General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE Domestic/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 TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Wells) #of wells ❑ Soil Borings) #of borings D Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pum Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other Groat Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal wafer) ❑ Sand Cement sack mix17 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: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 D ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKER C, PE LAWS. IW. NOT CE REQUIRED FO INSPEC S -PLEASE CALL(209)953 69 SIGNED TITLE DATE IE JO N NV R N NT T A MENT U E ONLoY Application Accepted By — — - -- Date & Area Employee ID# Grout Inspection By Date J SPECIAL Well Permit Pump Inspection By�r��rr1 _ Date C1/6 ❑ WAIVER Received Soil Boring Inspection By — Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Permit/ Invoice# Well ID# Co es Info AP Cash Remitted ate Service Request wPcn 9 EHD 43-06 6/11/2019 WELL/PUMP PERMIT