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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 �j 9 www.S ov.oC /ehd �EXPIIKES 1 YEAR FROM FROM UATE ISSUED JOB ADDRESS of A 0 V �I vy CITY/ZIP J / O G f'i 7-0;V / 7 �ZO 3 G LoL Ar/ r� /Gy 3 ao --- y "�'"` CROSS STREET p _ __ `C aPN PARCEL SIZE LAND USE APPLICATION #a-,�_/f/y4 OWNER NAME / 0 O J -FOG%2 7—O _ PHONE Z �_! /67 Y. O ZelL OWNER ADDRIESS _ Z Z d 11` W • W,45-0 T/t/,<T-a A/ Sly, CITY/STATE/ZIP 5 ToG/! r*A1, AZ s •r Z 03 CONTRACTOR ,lilToOlr 6A 4,7-H G Fa �S ,< PHONE �`A/ - 633 - roor CONTRACTOR ADDRESS f r 0- 4,06x4saJ -r-7' CITY/STATE/ZIP_ fLD.VA E ,i -A 920 de Y I / SUBCONTRACTOR/CONSULTANT &%N T /r�/ G �/" `. PHONE �6 !6T Z -�Ir SUBCONTRACTOR/CONSULTANT ADDRESS / 5'� Z SA A✓TA AvA AwF CI TY /S TATE/ZIP '6,4 14A'M ftA f c e,41 7 r8j LICENSE XC -57 ❑ C-61 ❑ D-09 ❑ Other NUMBER �7 ! '7 EXPIRATION DATE_�� BILLING PARTY: OWNER I I CONTRACTOR BCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING,: I General Mineral/Coliform Bacteria (439 1) 1 Dibromochloropropane (4392) Arsenic (4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 6LSoil Sampling/Characterization El Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK n New Well ❑ Replacement Well r3 Well Alteration/Modification 04 Other LP T ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # ofborings OLGeotechnical orings ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair A ❑ New Pum 1 --;Pum Replacement D Pum Repair ii Raise Well CasingP WELL CONSTRUCTION p� Drilling Method F] Mud Rotary 1i Air Rotary ❑ Auger ❑ Cable Tool .Push Point • ❑ Other `\ ce Proposed Well Depth'0 -/$O f ft Excavation in diameter ❑ Open Bottom 7 Gravel Pack/Gravel Size ___0rrir4iameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft 4411 ?0 Well Casing Diameter Vin Thickness/Gauge/ASTM Sched 11 Steel CI Plastic ❑ Stainless Steel ❑ Otht 40 Grout Seal Depth ft *-Neat Cement (94 lb bag/5-10 gal water) P. Sand Cement _ H� I ❑ Bentonite (20% solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall Other MSF D Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other C Concrete Pedestal DDimensions: Width it Length ft Thick in ❑ Christy Box ❑ Stove Pipe I UMP n Submersible❑ Turbine ❑ Other HP Pump Set It Standing Water Level ft 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAI' 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. MINIM/U%M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED r ( _ _ TITLE $ vZ0lL z -5V DATE /°_ T m D O O m m Application Accepted By Grout Inspection By Pump Inspection By Date IWAIVER Received Soli Boring Inspctio By Date _ ( I Constructed Well Depth _ ft AMENTS �-per ltiW2 P Tt7 f 0 3 _X& n?�'rI IL- 9 Id -Check#/ - -TService Permit/ Re - ■I� FUR `./OFF �I��ii% EHD43-06 6/11/2019 WELL /PUMP PERMIT