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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 10,6 pLAL1�G✓,� CF CITY/ZIP m <br /> CROSS STREET(DiV VI& O EG1C L-�APN 07C2 C2?�'O 2R '�V PARCEL SIZEQIILAND USE APPLICATION# <br /> OWNER NAME 1/0�!j yg-IC:S PHONE N <br /> OWNER ADDRESS ` d/ 4SP&VAyoo tSIV CITYISTATE/ZIP g0or r!% CA- ffZ-D2 <br /> CONTRACTOR V 4 w D-ALiAr '[" IeV 6_ � PHONE <br /> CONTRACTOR ADDRESS ! 37 7 A,— CITY/STATE/ZIP 64yT 91632 632 <br /> ` 6JSUBCONTRACTO �- " ( APHONI- <br /> SUBCONTRACTORICONSULTANTADDRESS;050 CITY/STATE/ZIP J-!c - <br /> LICENSE - C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 720fn/ EXPIRATIONDATE <br /> BILLING PARTY: <br /> ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial D Water Quality Monitoring XSoil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well 0 Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> # <br /> ❑ Monitoring Weil(s) #of wells �nSoii Boring � #of borings of boringss)_ geotechnical �� <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 ❑ Air Rotary Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 2- 7C/0 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 ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth /0 ft ANeat Cement(94/b bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ 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 48 H ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209)95P-7,697 <br /> SIGNED TITLE �rEv�oG DATE 'Z <br /> N <br /> F T <br /> ` EPARTMENT USE ONLY <br /> Application Accepted By Date�/ q�. Area Employee ID# <br /> Grout Inspection By Date ( 11 SPECIAL Well Permit <br /> Pump Inspection By A Date A LI WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Date Permit) Invoice# Well ID# <br /> Codes Info By _MRST Remitted Service Request# <br /> 457Z CT-2 517 i�j 940 -7,13/101 WWYMI <br /> EHD 43-06 6111/2019 WELL/PUMP PERMIT <br /> �a �-(' `fa"�/(SLt01-o�Itr r��L c- -,c�� eoc) �/3�'2 <br />