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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 D/ /Q CALL(209)209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS SYLo X /L f4J"r�IT,)G CRY/ZIP `J D 1 952 Yo <br /> m <br /> .f D <br /> CROSS STREET C6WrNVY 44%/e APN Oqr-p2 0-3'0-O'PARCEL SIZE `•_- LAND USE APPLICATION# y A <br /> OWNER NAME Lo D/ /V.V1GI EO fYH�°� DlJla./c? PHONE IOY�No. 1111, y <br /> OWNER ADDRESS /1°S E• V1tiE rr• CITY/STATE/ZIP 100/ <br /> CONTRACTORy4J��''fCE-Kuk�- 9�JOLt4tBI PHONE <br /> CONTRACTOR ADDRESS .1 /-/�40�7&/�Q4 ��VO. CITY/STATE/ZIP L/•I9L. (A �f>i f6 Q� <br /> SUBCONTRACTOR V ✓✓ (/��LL�'�G' PHONE•�0d7—416 6( -774b <br /> SUBCONTRACTOR ADDRESS /J;1 fu 4-t K4�j� D2• CITY/STATE/ZIP (l'��'� C`r //��2- <br /> LICENSE C-57 C-61 D-09 Other NUMBER 721✓ "OY EXPIRATION DATE 311'!V2 0 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> n!sr <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells X Soil Boring(s) _ #of borings Geotechnical #of borings <br /> Out-Of-Service Well !`Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary 7�It Rotary XAuger Cable Tool Push Point Other <br /> Proposed Well Depth(/—,�I�94 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 Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 1;_ ICb?ft Jeat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other jgkq E Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible 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 /> MIN M 48 HOU ADVANCE NOTICE REQUIRED FOR ILNSPECTIONS-PLEASE CALL(209)953 70697 <br /> SIGNED TITLE GEoG b C-�� DATE '6 <br /> �1 <br /> 19 <br /> VORVIBC SMENT <br /> ART ENT US O LY <br /> Application Accepted ByMOW le Areae Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By A, !(Z".te T7GConstructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Permit/ <br /> ods Info By. Cash Remitted Date Service Request# Invoice# Well ID# <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />