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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 209 953-7691 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 10'/ /- RS'Z I <br /> JOB ADDRESS ,�(`/-'�^ ''1{' Racon f G� �y�() CITY/ZIP V rm <br /> CROSS STREET-" WL,&-- /Clf(1/" ^k'1APN I�j to Q(,1t&J PARCEL SIZE�LAND USE APPLICATION# yA <br /> OWNER NAME PC4 tiro' �/& V7� �I�`C//,,C �� PHONE 9 <br /> OWNER ADDRESS ir_ 1/� CITY/STATE/ZIP �{G (� <br /> CONTRACTOR t�..jajA � nn (� C PHONE /fie q`cr 113 J <br /> CONTRACTOR ADDRESS 'Ubj 4-[!5L1QJ' S , 100 CITY/STATEIZIP U�G c,4 J W� <br /> SUBCONTRACTOR /C r n,✓n PHONE C++ <br /> SUBCONTRACTOR ADDRESS =`r N t% CITYISTATEIZIP , Q Z_ <br /> _ /q <br /> LICENSE C-57 C C-61 D D-09 D Other NUMBER 10 -+V ExPIRAnoN DATE 1 W <br /> DOMESTIC WELL SAMPLING:n General Mineral/Coliform Bacteria(4391)n Dibromochloropropane(4392)n Arsenic(4393) <br /> INTENDED USE 7 Domestic/Private n Irrigation/Agricultural E Industrial D Water Quality Monitoring /Soil Sampling/Characterization <br /> 7 Public Water System <br /> If dffferent from O—ar.. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 7 New Well D Replacement Well C Well Alteration/Modification :1 Other <br /> 7Monitoring Well(s) #of wells E Soil Boring(s) #ofbodngs Geotechnical #ofbonngs <br /> 7 Out-Of-Service Well C Out-Of-Service Well Renewal D Cross-Connection Repair <br /> -1 New Pum -1 Pump Replacement n Pump Repair n Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method /Mud Rotary n Air Rotary pf Auger n Cable Tool -1 Push Point n Other <br /> Proposed Well Depth SO ft Excavation in diameter L Open Bottom L Gravel Pack/Gravel Size in diameter <br /> 7 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched E Steel C Plastic -1 Stainless Steel 7 Other <br /> Grout Seal Depth ft /Neat Cement(94/b bag/5-10 gal wafer) C Sand Cement sack mix17 gal water <br /> 7 Bentonite(20%solids) D Other <br /> Grout Placement Method ;(Pumped 7 Free Fall 7 Other 7 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 1 1 Driller I Pump Contractor 1 Other <br /> _1 Concrete Pedestal ElDimensions:Width ft Length ft Thick in n Christy Box ❑Stove Pipe <br /> PUMP -1 Submersiblen Turbine n 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 /> MINIMUM 48 HO AD NOTICE REQUIRED FOR INS _ <br /> CTIONS-PLEASE CALL(209)9/5' ^76 7 <br /> SIGNED l�i -;�? TITLEp I C'1DATE f7 J IM <br /> RSC���r <br /> EtvE® <br /> SUN 0 3 2019 <br /> N�RQUIN COUNTY <br /> LTH D gRTMENT <br /> c <br /> RTMENT U E ONLY <br /> Application Accepted By DateI)eAreaeEmployee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Z I Date WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth ft <br /> COMMENTS Vjtoi <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By_ Cas Remitted ServiceR #est# <br /> EHD 4146 revised 4114118q T; -717 <br /> 1 <br /> I�Yn� 7{/-`/'/L WELL(PUMP PE,, <br />