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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.s Ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED Ln JOB ADDRESS (AYSIA IA e•1 An rmk (`�oune, CITY/ZIP Sh(A+b h C 1+ q say a m D CROSS STREET APN��P�-r 7a- c7 PARCEL SIZE Z�LAND USE APPLICATION# O xl -�v0 Ch OWNER NAME ��. PHONE ,, ) OWNER ADDRESS L 1-t u�- da /A CITY/STATE/ZIP �'�(�/`V, 1(,} C� q5-,:g i� CONTRACTOR - ] PHONEQV /'q�� ,3 i D CONTRACTOR ADDRESS CQ ( ✓ ( CITY/S'rATE/ZIP SUBCONTRACTOR/CONSULTANT PHONE SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP N PIT/ LICENSE `"C-57 ❑ C-61 ❑ D-09 I] Other NUMBER Ute_ EXPIRATION DATE BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING:I General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring U Soil Sampling/Characterization U Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well 11 Well Alteration/Modification 11 Other U Monitoring Well(s) #of wells 11 Soil Boring(s) a of borings ❑ Geotechnical A of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump X Pump Replacement ❑ Pump Repair U Raise Well Casing WELL CONSTRUCTION Drilling Method f] Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom I I 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 Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water F.I Bentonite(20%solids) ❑ Other Grout Placement Method r] Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal❑Dimenslons:Width ft Length ft Thick in CI Christy Box ❑ Stove Pipe fPUMP )(Submersible 0 Turbine ❑ Other HP Pump Set ft Standing Water Level r—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. I N IV,AHU NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209) 53-/76 7 ,/ SIGNED TITLE DATE 17 �T 0111 O — q — N IFP RTMENT VSE N L Y TMFN�, Application Accepted By —� Date C Area 44&4 Employee ID#� Grout Inspection By Date SPECIAL Well Permit Pump Inspection By (rt�ltj& �wJ. L Date 2/*7 UZO WAIVER Deceived Soil Boring Inspection By Date Constructed Well Depth _ ft COMMENTS PE SC Received Check#/ Amount Permit/ Codes Ifo By_ Cash Remitted Date Service Request# Invoice# Well ID# n EHD43-06 6/11/2019 WELL/PUMP PERMIT