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WELLIPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HA7.ELTON AveNue - STOCKTON DA 96205 -6232 (209) 468-3420 NON-REFUNDABLE PERMIT WWW.SjgOy-Org/ehd EXPIRES 11 YEAR FROM DATE ISSUED Joe AODREss._� � „Q ✓l�,yJ CITYIZIP /�'� L CROSS STREET-_._�-....�A+P /N ,IO ��..0>f1 `-�O PARCEL SIZE..17 LAND Use APPLICATION 9 p b OWNER NAME ,-,�YCfly `I_1 / i�GrY•:. f'!/'•-.�,/� �j PHONp fi_ ✓/ a ,++ w OWNER ADDRESS uf' '1+� � LJK a- CITYISTATEIZJP_ `j5t-- 10-/4- CONTRACTOR _ ,JC IJJ,`/' '^'�Al! Lt_ /�...._ +�, PP ONE 93r d�L�-+%G✓ CONTRACTOR ADDRESS-� -Y ✓lL"? /�"' - CITY/STATE/ZIP G+0"4°0Z"' SUSCONTRACTORICONSULIANT .,G_�+ '�Z�LL ,/ -� PHONE .TANT ADDRESS LICENSE'$7 )&%l s`I D-09 BILLING PARTY: OWNER CITYISTTATEIZJP U Other NUMBER 4 9 91 I0 EXPIRATIoN DATE .-CONTRACTOR SUBCONTRACTOR/CONSULTANT _-_- DOMESTIC WELL SAMPLING: General Mineral/Colifonn Bacteria (4391) Dibromochioropropane (4392) Arsenic (4393) INTENDED USE ji.VUOme.S11C/Private i IrrigationtAgricultural C�! Industrial ,0i Water Quality Monitoring 0 Soil Sompling/Charact / 7 Public Water System_ It (afferent from Ganef: Water S1's1 m Name Cminc7 Ni ma or Phone Number TYP F WDRK'MNew Well f..) Replacement Well : ! Well AllerationfModification Cl Other 11 Monitoring Welts) p of wells i.I Soil Boring(s) a of boo il, �J Geotechnical arv-p OLA -Of -Service Well o Oul-Of-Service Well Renewal Cross -Connection Repair i H"AL1'H U New Pump `:! Pumo Reniacemenl is Pumn Renzw Raise IAhall Caeinn Drflilnq Method ,,SdMud Rotary ri Air Rotary CI Auger 0 Cable Tool Push Point Other Proposed Wall Depth .. 3_70 It Excavation %Z in diameter I:i Open Bottom >wtravel Pack/Gravel Size in diameter 0 Conductor Casing in diameter / Conductor Casing Depth ft .--•• Well Casing Diameter _/a in Thickness/Gauge/AST'M Scned ,feel *Plastic Cl Stainless Steel t:; Other Grout Seal Depth_ fQD_ it Il Neat Cement (94Ib 7hIO-10 gal waterl ii Sand Cement _ -sack mix17 gal water ,Pt13entonlfe (20% soilds) F! Other Grout Placement Method f) Pumoed I Free Fall i. Other ❑ Retardant / Accelerator (nmol PE _ -..__.._.._._r_ DESTAL Installed B.._.o y . Driller o pump Contractor T!. Other u Concrete Pedestal ODhnensions- Width _ it Lenoth it Thick in U Christv Box L) Stove P)De PUMP JVSubmersible_': Turbine i.. Other HP_ .:! Pump Sat _ ft Standing Water Level 12Y�:t- If 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE. WITH ALL WORKERS COMPENSATION LAWS. MINI R CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9)53-7 97 SIGNI::D _ % L TITLE&"/,: DATE Application Accepted By Grout Inspection By Pump Inspection By Soil Boring Insp� lion By _ COMMENTS-__1fL_e]______ C.01J, Q.. iL-_ _ r -u Date Date Date Date Itil- Employee iDN�_^^- SP CIAL Well Perinit WAIVER Received /� ted Well Depth 3V ft 0104:1.06 tW1112018 WELL HUMP PERMIT