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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1666 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)465-3420 <br /> NON-REFUNDABLE ER I CALL(2M 953-7697 FOP,IN PECTIONS EXPIRES 1 YEAR FSOM D ED <br /> I lea �J OYI N i to I Al <br /> JOB ADDRESS CIrvILP `�'• m <br /> D <br /> CROSS STREET 14 WAVV,Y APN �(/ PARCEL SIZE LAND US APPLICATION# F <br /> to <br /> OWNER NAME (/�� (//(PHI/QNE V <br /> OWNER ADDRESS 79 <br /> !�"" -CITYISTATEIZIP -- <br /> yl <br /> S \ L PHONE / U <br /> CONTRACTOR <br /> U I,v{ <br /> CONTRACTOR ADDRESS I c <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS ' __ Cl/TTY/STATEIZIP <br /> LICENSE C-57 C-61 0-09 Other NUM l!i EXPIRATION DATE <br /> DOMESTIC WELLS PLING: General Mineral/Coliform Bacteria(4391) Dibromochioropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Atteration/Modification Other 1 <br /> Monitoring Weli(s) #of wells Soil Soring(s) a of bor,ngs Geotechnical n of borings <br /> Out-Of-Service Out-Of-Service Well Renewal Cross-Connection Repair s <br /> New Pump Kump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth It f1 <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other \cy1 <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water ^ <br /> Bentonite(20%solids) Other �t <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Len g It Thick in Christy Box Stove P' e <br /> PUMP Submersible Turbine Other HP Pump Set It Standing Water Level It <br /> I 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 CAL CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKE NSATION LAWj§7A�E <br /> �J 1 <br /> MI UM 24 HO NOTICE IRED FOR QSPECTIONS-PLEASE CALL(209)953-7697 W <br /> SIO. D TI E VY Vi (/�,� DATE N <br /> C <br /> RF YMFNT <br /> CF jV�� <br /> j4 <br /> N 1 2019 <br /> Vj <br /> NV"RoEk <br /> LTy� PM ���TY <br /> R <br /> Ep R T M E N15/j! SE NLY <br /> Application Accepted By Date Area Employee ID#)� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By ate WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth <br /> COMMENTS <br /> PE SC Received Che Amount Date Permit! Invoice# WellID# <br /> WeInfo miffed Service PVwest# <br /> EHD 4346 6!01116 WELL/PUMP PERMIT <br />