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t` WELUPUMP PERMIT <br /> } SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELToN AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT ` CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> SS <br /> JOBADOREI1 ion ryV` crTYZP I %r, CA 1153AC m <br /> K + a � i 7.�r� I <br /> CROSS STREET �L\`V APN /� RCEL SQE LAND USE APPLICATION# A <br /> OWNER NAME VCG\T�(T�..i (C.[� PHONE °? <br /> OWNER ADDRESS CnY/STATE21P CY�\G•� rC'A �1� 'Zy <br /> CONTRACTOR O' tPG.^1 ` PHONE <br /> CONTRACTOR ADDRESS (J 7 C TQ. CITY/STATE/ZIP GYG�, r Lk '1'3 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CIITTY//STA/TEE/ZP <br /> LICENSE AC-57 F,C-61 n D-09 Other NUMBER EXPIRATION DATE -3 <br /> DOMESTIC WELL SAMPLING:n General Mineral/Coliform Bacteria(4391)n Dibromochloropropane(4392)n Arsenic(4393) <br /> INTENDED USE XomesticJPrtvate Lj Irrigation/Agricuhural a Industrial a Water Quality Monitoring a Soil Sampling/Characterization <br /> n Public Water System <br /> 11 cgffweM hom Owner. Waley system N.- Conted Nems a Phone Number <br /> TYPE OF WORK a New Well a Replacement Well a Well Alteration/Modification u Other <br /> F Monitoring Wei(s) #of wells n Soil Boring(s) •or borings n Geotechnical #or borings <br /> Li Out-Of-Service Well u Out-Of-Service Well Renewal a Cross-Connection Repair <br /> New Pu n Pump Replacement n Pump Repair n Raise Wei Casing <br /> WELL CONSTRUCTION �` 1/�'�'• <br /> Drilling Method n Mud Rotary n Air Rotary n Auger n Cable Tool n Push Point ❑ Other V C Fo <br /> Proposed Well Depth ft Excavation in diameter n Open Bottom n Gravel Pack/Gravel Size in diaMeteO <br /> n Conductor Casing in diameter / Conductor Casing Depth ft n n n S,qN A I!, 2019 <br /> Well Casing Diameter_in Thidmess/Gauge/ASTM Sched Steel Plastic Stainless Steel n Other <br /> Grout Seal Depth ft n Neat Cement(94 lb bag/r10 gal water) n Sand Cement sack mixt/ R)AQ 201,91 <br /> C <br /> n Bentonite(20%solids) n Other <br /> Grout Placement Method n Pumped n Free Fall n Other n Retardant/Accelerator(name) C O A&NT� <br /> PEDESTAL Installed By a Driller -'Pump Contraclor, a Other MFNT <br /> Concrete Pedestal nDimensions:Width it Length it Thic k ..&- in n Christy Box Stove Pipe <br /> MP Submersible-Turbine a Other HP Pump Set V 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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE I DATE Willy., <br /> 3 <br /> ,Y <br /> TMENT U E ONLY Z -� <br /> Application Accepted By Date AreaEmployee IDS� <br /> Grout Inspection BY Date L PECIAL Well Permit <br /> Pump Inspection By 4+ 5�,�/ hw\li'\ Data Z ��� WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Chec AmountDatePermit/ Invoice# Well ID# <br /> Coots Info emitted Service R nest <br /> EHD 43-06—sod 4/14/18 WEI I./PUMP PERMIT 4A <br />