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db <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 9533--7,697 FOR INSPECTIONS QEXpPIIREES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 2 1�S :TacV_ TO,c= !9A CITY/ZIP ` _\Pte+,1 �5 b(ob tDs7 <br /> CROSS STREET W K`Ot,Y\ APN Z 2 16'- '10 -2(0 PARCEL SIZEy�LAND USE APPLICATION# A <br /> l/� A <br /> In <br /> OWNER NAME S zf E.�1 1Libt• Y\ �T� PHONE w <br /> OWNER ADDRESS 2,1`�1 J• �QG�T#Zwle_ kC)Q0� CR\'/STATEMP F.\gQ(1 I CA <br /> CONTRACTOR V �at\,11 V\lG_ PHONE 209-ci81 - 11 Ib5 <br /> CONTRACTOR ADDRESS �\3 g\QGY+�rY3't'S� -C>y� C CRY/STATE/LP bac.\i I C-A hlsko 3s j_ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CIT'/STAT,E1ZP <br /> LICENSE C-57 11C-61 n D-09 n Other NUMBER 17 CA L4 EXPIRATION DATE &O/20 <br /> DOMESTIC WELL SAMPLING:L General Mineral/Coliform Bacteria(4391)r1 Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private n Irrigation/Agricultural n Industrial n Water Quality Monitoring n Soil Sampling/Characterization <br /> ❑Public Water System <br /> If dllfemnt from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well n Replacement Well n Well Alteration/Modification ❑Other <br /> nMonitoring Well(s) #of wells K Soil Boring(s) I #of borings F1 Geotechnical #of borings <br /> ❑Out-Of-Service Well n Out-Of-Service Well Renewal n Cross-Connection Repair <br /> n New Pum ❑Pump Replacement n Pump Repair n Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method n Mud Rotary n Air Rotary KAuger n Cable Tool n Push Point n Other <br /> Proposed Well Depth ft Excavation in diameter n Open Bottom n Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad n Steel n Plastic n Stainless Steel n Other <br /> Grout Seal Depth 35-Li O ft )(Neat Cement(94 Ib bag/5-10 gal water) n Sand Cement sack mW7 gal water <br /> F1 Bentonite(20%solids) n Other <br /> Grout Placement Method Pumped ❑Free Fall n Other n Retardant/Accelerator(name) <br /> PEDESTAL Installed By n Driller n Pump Contractor n Other <br /> C Concrete Pedestal nDimenslons:Width ft Length It Thick in ❑Christy Box n Stove Pipe <br /> PUMP n Submersibles 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 /> MI M 4 Ug,gDVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED ___ `J+r�- TIME k n�.ruC! DATE <br /> AcNjF�r <br /> FIVE® <br /> 04 2019 <br /> QUIN CO <br /> MENTUNTM <br /> EPgRTIH NT <br /> -TFFFF-f+ <br /> PARTMENTs USE ONLY <br /> Application Accepted By Date �/� � Are ak <br /> �Efnploy.i ION . <br /> Grout Inspection By Date j7 n ell PefTlit <br /> Pump Inspection By Date c� n WAVER RBcelVed <br /> Soil Boring Inspection By D to l� 1 nstru Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well IDN <br /> Cods Info BY Remitted Service Re nest# <br /> EHD 43-06 rsvlsed 4114118 WELL/PUMP PERMIT <br />