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e A <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HE <br /> ALTH DEPARTMENT(f., 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMI D '1 5 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> Joe ADDRESS Ov fl-;Ve CITY/ZIP 1'd e`? 9 6- <br /> 137(a m <br /> CROSS STREET APN 21q-500-OW- a <br /> I�dOPARC EL SIZE I QC.YYSf LAND USE A.PLICATION# <br /> 1 (�0 ,L y <br /> OWNER NAME PHONE (i� <br /> OWNER ADDRESS •7 CITYISTATE/ZIP 1�' ( (70 <br /> CONTRACTOR I I s PHONE <br /> CONTRACTOR ADDRESS JD.I. K\�1l-rte d.1ly� CITY/STATE/ZIP �f 1 'q&1 e /� <br /> SUBCONTRACTOR PHONE (y04) 7-7 ` <br /> SUBCONTRACTOR ADDRESS A. CII1TY/STATEIZIP <br /> LICENSE C-57 C-61 D-09 Other NUMBER IWi0q EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: 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 I-,Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification tJ Other <br /> MonitoringWell(s) #of wells SoilBoring(s) ltofbndngs KGeotechnical_<°of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal f Cross-Connection Repair <br /> New Pump PumpRe lacement a Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method I Mud Rotary Air Rotary ?-Auger Cable Tool )(Push Point Other <br /> Proposed Well Depth ft Excavation 'j,r(0 it in diameter Open Bottom i Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic i Stainless Steel Other <br /> Grout Seal Depth ft 74Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other K_�L4A 'r I li Wskii.E Is. vJ?.*'V r- Gr- >�3(1� <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 Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> U 48 HOUR ADVANCE NOTICE REQUIRED FOR INSP CTIONS-PLEASE CALL(209)95?-7F97 <br /> SIGNED TITLE tag!q If <br /> S DATE12,1241(1 <br /> NT <br /> VIED <br /> 2018 <br /> S N COUNTY <br /> MENTAL <br /> PART MENT <br /> DE R A TMENT) USE N L Y , !z <br /> Application Accepted By l Date) Z Area �ty l• EmpIoyee ID# 5� Jl <br /> Grout Inspection By Date VSPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring In ction By Date Constructed Well Depth ft <br /> OMMENTS rC lY V V '� — ^Lh o Z <br /> to _ <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B s Remitted Service Request# <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />