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WELLIPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 NON-REFUNDABLE PERMIT WWW.S oov.Or /ehd EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS • 6 CITY/ZIP GISa�s �' m CROSS STREET APN r � DoPARCEL SIZE -VaqALAND USE APPLICATION# OWNER NAME PHf�QN7E� _ (Mn OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR O(D ` J PHONE / CONTRACTOR ADDRESS CITY/STATE/ZIP C SUBCONTRACTOR/CONSULTANT PHONE 11-14 SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP YV PT LICENSE KC-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE BILLING PARTY: ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE X 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 Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump XPumpReplacement ❑ 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 Grout Seat Depth ft ❑ Neat Cement(94 lb bag/5-90 gal water) ❑ Sand Cement 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❑Dimenslons: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 WORKER OMPENSATION LAWS. ItVrrA1q,'A_NCE NOTICE REQUIRED F I SPEC -PLEASE CALL(209)953-7697 SIGNED Yv� TITLE 211U DATE 74 OQ H M ENT SE ONLY �4rMS'NT 44'uk_�;IaLate "_� Application Accepted By Area Employee ID# Grout Inspection By Date 1 ❑ SPECIAL Well Permit Pump Inspection By Q Qllle`I IJ, l Date lb L671c, LI WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE Sc Received Check# Amount Permit/ Codes Info B s R mitted Date Service Request# Invoice# Well ID# OO EHD 43-06 6/11/2019 WELL/PUMP PERMIT