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w WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 NON-REFUNDAEILE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESSVI V Y CITYIZIP 7 /�/` "153 3-7 m J 0544 DA-I M Pf-APN L� CROSS STREET /0 1� C j PARCEL SIZE LAND USE APPLICATION# p OWNER NAME — r 41 G\ (, PHONE OWNER ADDRESS 1 v n ('O n CITY/STATEIZIP 2>n 1, pOH V ^� CONTRACTOR �C/1 K� ( PHONE G ( — IJ S CONTRACTOR ADDRESS ,I — j1 d CrY/STATEIZIP G q NZ SUBCONTRACTOR/CONSULTANT V i VI �`j r[111 1 L10. �C-" PHON//E �/I/� 416 1— �70 SUBCONTRACTOR/CONSULTANT ADDRESS I«J V' el 6L Y- .� Df i CIT-YY/SSTTATE/IZ�IP a ✓ gS�70p o LICENSE 4C-57 f- -61 rl D-09 7 Other NUMBER W V EXPIRATION DATE / '� (iV?- BILLING PARTY: ❑OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)G Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE 7 Domestic/Private ❑Irrigation/Agricultural C Industrial ❑Water Quality Monitoring 4 Soil Sampling/Characterization 7 Public Water System If different from Ovmer. Water System Name Contact Name or Phone Number TYPE OF WORK i New Well i i Replacement Well i Well Alteration/Modification i i Other -1 Monitoring Well(s) #of wells F Soil Boring(s) #of borings dGeotechnical �4 _#of borings J Out-Of-Service Well L Out-Of-Service Well Renewal D Crass-Connection Repair 7 New Pum :1 Pump Replacement ❑Pump Repair ❑Raise Well Casing WELL CONSTRUCTION Drilling Method 1I(Mud Rotary ❑Air Rotary 'd Auger ❑Cable Tool 7 Push Point ❑ Other Proposed Well Depth 13-SO ft Excavation in diameter L Open Bottom C Gravel Pack/Gravel Size In diameter 7 Conductor Casing in diameter / Conductor Casing Depth it Well Casing Diameter_in Thickness/Gauge/ASTM Schad C Steel C Plastic 7 Stainless Steel ❑Other Grout Seal Depth /s'S O vp ft Neat Cement(941b bag15-10 gal water) C Sand Cement sack mix/7 gal water -1 Bentonite(20%solids) n Other Grout Placement Method 4 Pumped -1 Free Fall 7 Other -1 Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller C Pump Contractor ❑ Other 7 Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP :1 Submersible❑Turbine D Other HP Pump Set it Standing Water Level ft I HEREBY CERTIFY THAT 1 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. MINIMUM 48 H I7jIR AD ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 j SIGNED l.f ' TITLE ✓� /'y/ 1 DATE /0 Gb I AA ENT VELA 2020 FFTT AUNTY DEPARTMENT USE ONLY HF-ALTHpE"py,�'ENTAL RT MENT Application Accepted By Zz— Date l� 3V c)d� Area �f��L) Employee ID# �I Grout Inspection Byti)!��-Date I.G ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVERReceived Soil Baring Inspection By Date Constructed Well a it ft COMMENTS ` �1 PE SC Received Check#1Amount Permit/Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# 3 3 50 EHD 43176 6/11/2019 /t /T I'n/'t �i WELL/PUMP PERMIT