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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.sjgov.org1ehd EXPIRES 1 YEAR FROM DATE ISSUED / Z' ` JOB ADDRESS CITY0P a m r� ^� D CROSS STREET OO APN O 0 0 Ll� PARCEL SIZE 0, I1-LAND USE APPLICATION# OWNER NAME PHONE �O l+ 2 / / u? OWNER ADDRESS 2-1 -11 V- if- L0.X1e- CITYISTATEMP 96a CONTRACTOR M oormcxyilS 1 Wa4ier Sc.IS�ZnA-, IVIG• PHONE —O9`q ( 2.10 CONTRACTOR ADDRESS Z I�-o W I (.✓)r� CITY/STATEZP 5fp n, C14 9$";;�/S SUBCONTRACTOR/CONSULTANT PHONE )1 144 SUBCONTRACTOR/CONSULTANT ADDNESS IN CITY/STATEIZIP Zy I r LICENSE )(C-57 ❑C-61 0 D-09 ❑Other NUMBER 4(n$81(o EXPIRATION DATE BILLING PARTY: ❑OWNER XCONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)G Dibromochloropropane(4392)G Arsenic(4393) INTENDED USE 0 Domestic/Private Cl Irrigation/Agricultural 0 Industrial ❑Water Quality Monitoring D Soil Sampling/Characterization D Public Water System If different from Owner. Water System Name Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well 0 Well Alteration/Modification ❑Other C Monitoring Well(s) #of wells ❑Soil Boring(s) 9 of borings D Geotechnical—#of borings ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair ❑New Pump XPumpReplacement C Pump Repair 0 Raise Well Casing WELL CONSTRUCTION Drilling Method ❑Mud Rotary 0 Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other Proposed Well Depth ft Excavation in diameter C Open Bottom C Gravel Pack/Gravel Size in diameter C Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_in Thickness/Gauge/ASTM Schad ❑Steel u Plastic ❑Stainless Steel 0 Other Grout Seal Depth It ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mixf7 gal water C Bentonite(20%solids) ❑Other Grout Placement Method 0 Pumped 0 Free Fall 0 Other C Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller D Pump Contractor C Other ❑Concrete Pedestal❑Dimensions:Width It Length ft Thick in ❑Christy Box 0 Stove Pipe PUMP Submersible❑Turbine 0 Other HPC Pump Set ft 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. 1 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. M H ANCE NOTICE REQUIRED FOR I P/ECCTTIOONNS-PLEASE CALL(209)953-69r SIGNED' TITLE lir=% ` DATE R gYMEN �c��VFO Mql 9 ?0 DEPARTMENT USE ONLY ��i /1fiCw,'v��'?0N,cot/ Application Accepted By /'�— Date 3 ly a� Area ��G Employee ID# '/' ` �'�C �pNR7. GroutInspection By Date ❑ SPECIAL Well Permit EHT Pump Inspection By Date / ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE Sc Received Check#/ Amount Permit/ Codes Info B s Remitted Date Service Re uest# Invoice# Well ID# 3 osb I EHD 43-06 6111/2019 WELL rPUMP PERMIT