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V <br /> ' WELL/PUMP PERMIT <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 INSPECTIQNJ EXPIRES 1 YEAR FROM DATE ISSUED <br /> Vlt71` f Ln <br /> ADDRESS I /ZIP vs't / D,0 qs3-30 m <br /> CROSS STREET <br /> V'i errs Rd APN PARCEL SIZ_ 2L <br /> AND USE APPLICATION# <br /> OWNER NAME M �`� PHONE w <br /> OWNER ADDRESS QQ CITY/STATE/LP <br /> CONTRACTOR �C/- /m]\ PHONE 7 <br /> CONTRACTOR ADDRESS I Y ✓V�• uV CITY/STATE/ZIP L `f H <br /> SUBCONTRACTOR r• PHONEVA c <br /> 3 k -010 <br /> SUBCONTRACTOR ADDRESS 7 V� CIN/STATE21P PQ 14 .�"f/ _Ali '/y <br /> LICENSE It C-57 1i C-61 ❑D-09 11 Other NUMBER,�3�k� EXPIRATION DATE 0 2l/I <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring f Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Ovmer. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well :1 Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings d Geotechnical of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pum ❑Pump 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 5 0 ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft d Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method j Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width It Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level 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. 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 /> MIINII�MUUMI 48 yry/J/'f{/'ADVANCE NOTICE REQUIRED FORy'/{��ISP TIO S-PLEASE CALL(209)953- 6977 <br /> SIGNED �`�/w 'J�!/y TITLE /V 6 <br /> DATE W <br /> IED <br /> 777 <br /> 3 2019 <br /> �GJIN COUNTY <br /> ENVII'MMENTAL <br /> JEATTWOEPARTMENT <br /> PAR MENT SE ONLY <br /> Application Accepted By Area Employee ID#AWQO <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection Bye Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted §Rice <br /> �Re uest# <br /> � VV <br /> EHO 43-06 revised 4/14/18 WELL)PUMP PERMIT <br />