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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 INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> C <br /> JOB ADDRESS S &Old CITY/Zip <br /> m <br /> D <br /> CROSS STREET l/1 I/ APN PARCEL SIZE LAND USE APPLICATION# [7 0 <br /> OWNER NAME J \C, ru�1 „� '� �`✓C-�-1 Crl Is PHON'E-.� I .`:L��� ��'�7-L�� 1 <br /> OWNER ADDRES ✓• G GTY A P <br /> CONTRACTOR `PHONE �� ✓�'tF <br /> CONTRACTOR ADDRESShv CITY/STATE/ZJP�)�J I 1-✓b <br /> SUBCONTRACTOR PHONE \\ <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP— <br /> LICENSE )(C-57 C-61 D-09 Other NUMBER )t I I EXPIRATION DATE :ZL I J <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE 0 DomesticfPrivate Irrigation/Agricultural Industrial D Water Quality Monitoring Soil Sampling/Characterization <br /> I-,Public Water System <br /> If diff erent Gam Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well 1 Replacement Well Well Alteration/Modification J Other <br /> 0 Monitoring Well(sl #of wells Soil Borings) #of bon"Bs Geotechnical a of borings <br /> D Out-Of-Service W I Out-Of-Service Well Renewal '1 Cross-Connection Repair <br /> ump Replacement Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point 0 Other <br /> Proposed Well Depth ft Excavation in diameter _. Open Bottom 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 Neat Cement(94 Ib bag/5-10 gal water) Sand Cement Sack mix/7 gal water <br /> J Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fan Other Retardant/Accelerafor(name) <br /> PEDESTAL Installed By Driller IPump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length if Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set it 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 UCENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> IN hh. f,L:, „i.3VANCE NOTICE 7`,.:�1iJIRED FORINSPECTIOl'.INSPECTIOP: -PLEASE CALL(209) 53-7697 <br /> `V <br /> TITLE Cr I f�� C/It", DATE <br /> It <br /> S 2019 <br /> /V <br /> P rAL <br /> rY <br /> MFNT <br /> EP RTMENT SE N L Y ,AA <br /> Application Accepted By Date Area-4a Employee ID#�/F��I <br /> Grout Inspection By Date PECIAL Well Permit I <br /> Pump Inspection By ��`�-'uu �,;1�:UQ S \'\4 -bate WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS _'Llr� t, (y',L)\ <br /> PE SC Received Check#/ Amount PermiU <br /> od Info B Cash emitted Date Service Re uest# Invoice# Well ID# <br /> 11190 -7-1 IA <br /> EHO 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />