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t <br /> � e <br /> WELL/PUMP PERMIT l } <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS )S 31-3 Nj. Sc V►e S 1z n CITYIZIP A CA(y)?0 ; C1 S�2 5?0 m <br /> r . , rR'��T � 1y334 Z <br /> D <br /> APN GC � PARCELSIZECROSS STREET LAND USE APPLICATION# <br /> f ( <br /> OWNER NAME te_" f PHONE <br /> OWNER ADDRESS WVA5/W w <br /> CITY/$TATE/ZIP <br /> CONTRACTOR V r;1�-{Q 7 T)LC &s y)j PHONE - 77 <br /> CONTRACTOR ADDRESS—? VL/` 4.7 CITY/STATE/ZIP G— 1A- 11C A 1-1 c)��� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS /-13Cjr Y/STATE/ZJP <br /> LICENSE ?LC-57 /,r,-61K <br /> -61 D-09 Other NUMBER S EXPIRATION DATE -71T 1 :20 <br /> DOMESTIC WELL SAMPLING:it General Mineral/Coliform Bacteria(4391)I 1 Dibromochloropropane(4392) 1 Arsenic(4393) <br /> INTENDED USE )k Domestic/Private 1 1 Irrigation/Agricultural I Industrial I Water Quality Monitoring is Soil Sampling/Characterization <br /> Public Water System <br /> If different from Ow ec Water System Name Contact Name or Phone Number AY • <br /> TYPE OF WORK ',f.New Well Replacement Well Well AReration/Modification Other <br /> 5 Monitoring Well(s) #of Wells Soil Boring(s) #of benngs Geotechnical n of borings ry <br /> � <br /> ngs ACIV <br /> 0 Out-Of-Service Well I Out-Of-Service Well Renewal D Cross-Connection Repair c �® <br /> t,NeW Pum i I Pum Replacement i Pum Repair 1 Raise Well CasingO <br /> WELL CONSTRUCTION ZO18 <br /> Drilling Method'(Mud Rotary _I Air Rotary i Auger^1 Cable Tool Push Point i Other VX <br /> Proposed Well Depth 3�a ft Excavation 1�t in diameter Open Bottom K Gravel Pack/Gravel Size \�`�— �tI�� QU�N L`OU <br /> Co ,; rc Cdr g Aia ate Crad;Go casing DcN� „ �k NME Nn' <br /> Well CasingDiameter In Thickness/Gauge/ASTM Sched C)19.;i Steel Plastic Stainless Steel i Other I n EP fN,r�� <br /> Grout Seal Depth t! ft I Neat Cement(94 Ib bag/5-10 gal water) )4 Sand Cement IG sack mix/7 gal water r MINT <br /> LI Bentonite(20%solids) -1 Other <br /> Grout Placement Method Pumped Ei Free Fall ii Other i Retardant/Accelerator(name) <br /> PEDESTAL Installed By 1 Driller I-_� Pump Contractor 1-1Other <br /> Concrete edestal[-Dimensions:Width�ft Length R Thidc n Christy Box L.Stove Pipe <br /> PUMP Submersible Turbine -Other HP_5 Pump Set_( _ft Standing Water LevelV ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 44/8 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)95 46P7 �1 <br /> SIGNED 14,T/ TITLE V Ge pre S A e,n-� DATE 7 1 <br /> IZIVI I I -F777-T-- I I I F I I I I I I I I I I + <br /> 5 <br /> PA MENT U E Y2LY <br /> Application Accepted By Date a Area Employee ID# <br /> Grout Inspection Byate PECI L Weil Permit <br /> Pump Inspection By Date4 � -;��1`ri WAIVER Received <br /> Soil Boring 1 pection By• Date Constructed Well Depth ft <br /> COMMENTS Q <br /> PE SC Receivedec Amount Date Permit/ Invoice# Well 10# <br /> Codes Ifo sh Re fitted Service Request# <br /> �D o� <br /> EHO 43-08 revised 4114/18 WELL/PUMP PERMIT <br />