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A <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> ' RON-REFUNDABLE PERMIT AL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Kf rn <br /> JOB ADDRESS A` CITY/ZIP ,c 37 m <br /> QGV'pd m <br /> CROSS STREET S APN_2 5$`D7PARCEL SIZE LAND USE APPLIICCAA�JTtIO(N## A <br /> OWNER NAME av / (/A PHONE (LIV -Q-z q s-4 P <br /> OWNER ADDRESS Rn , (^ CITY/STATE/ZIP TIj?'jo y CA, <br /> 7 -6Y2 <br /> CONTRACTOR �1 ��// D� �/ <br /> CONTRACTOR ADDRESS b (�(S 5-/�.,//�O i� CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE (/e-57 I. C-61 D-09 I Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) 1 Dibromochloropropane(4392)1 1 Arsenic(4393) <br /> INTENDED USE --BDRfestic/Private i Irrigation/Agricultural I Industrial _Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK i New Well �lacement Well Well Alteration/Modification Other <br /> i Monitoring Well(s) #of wells SoilBoring(s) #of borings SlGeotechnical 9o borings <br /> Out-Of-Service Well i Out-Of-Service Well Renewal I I Cross-Connection Repair <br /> New Pump i Pump Replacement - Pump Repair t Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ..MII'd Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth .3g:PgZ ft Excavation 12 Xon diameter Open Bottom ,i Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter&in Thickness/Gauge/ASTM Sched 1 Steel r Plastic Stainless Steel Other <br /> Grout Seal Depth /A O ft _i Neat Cement(94 Ib bag/5-10 gal water) i Sand Cement sack mix/7 gal water <br /> -W-Intonite(20%solids) Other <br /> Grout Placement Method iiI , Free Fall 1 Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By i Driller i Pump Contractor --05ffTe-r <br /> Concrete Pedestal ,Dimensions:Width ft Length It Thick in Christy Box Stove Pipe <br /> PUMP Submersible.i 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 COU TY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AN ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS C MPENSATION LA <br /> MI IMUM S NCE OTICE FOR INSPECTIONS LEA E CALL(209)953-7697 <br /> SIGNED TITLE DATE — �-I4 <br /> t <br /> PAYMENT <br /> o� RECEIVED <br /> JUL000 <br /> 10 2019 <br /> AN JOAgU)N COUNTY <br /> o ENVIRONMENTAL <br /> EALTH DEPgRTMENT <br /> ,r <br /> A MENT U E NLY <br /> Application Accepted By "I e O / Area Employee ID# <br /> Grout Inspection By Date 9 PECIAL WBII Permit <br /> Pump Inspection By Date I WAIVER Received <br /> Soil Boring Inspection By Date ConstructedW II Depth 1 ft <br /> COMMENTS <br /> (A--'r � t O <br /> PE SC Received Check#/ Amount Permit/ <br /> Code Info By Cash mi ed Date Service Request# Invoice# Well ID# N <br /> 7 <br /> • ��v W�GY�3�7�? . <br /> EHD43-06 revised 4/14/18 WELL/PUMP PERMIT <br />