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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 7868 EAST HAZELTON AVENUE-STOCKTON CA 96205-(209)"461Y'=314 U L� <br /> NON-REFUNDABLE PERMIT n ` CALL 20/9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS J Z v \/Ct CITY/LP �\�c♦C ( ) �J m <br /> D <br /> CROSS STREET APN -&4 q PARCEL SIZE LAND USE APPLICATION# z <br /> 1 f J� <br /> / m <br /> OWNER NAME �i T- l t'�771cLV PHONE S )y '• 7 S(4) (6 N) w <br /> OWNER ADDRESS rCU \31Jk �l /' CITY/STATE/LP FQ t HOrNL'� C—'111 S1 / ..7 <br /> CONTRACTOR tJL(t p ?N W7,!1 SG Y V 1 C PHONE—5-7Y'G JL� C- <br /> /; l Q <br /> CONTRACTOR ADDRESS T '7 /�(. 1M Cy,> (e/ V! CITY/STATE/LP L41"jC/CS L; /1 J�7 <br /> S I <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 Y-C-61 D-09 Other NUMBER L—ZOI'i I EXPIRATION DATE li ZG <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE omestic/Pnvate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> i Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well Replacement Well Well Afteration/Modificetion n Other <br /> ❑Monitoring Well(s) #of wells SoilBoring(s) #ofborings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> ew Pum Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth 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 SchedI Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) i_ Other <br /> Grout Placement Method Pumped '1 Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller i Pump Contractor Other VI <br /> Concrete Pedestal_IDimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP ubmersible Turbine Other HP_5- - 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 /> MINIM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE 20/ 1 / <br /> YMENT <br /> CEIVED <br /> Y 23 2019 <br /> AQUIN COUNTY <br /> IRONMENTAL <br /> H DEPARTMENT <br /> PAIRTMENT US O LY <br /> Application Accepted By epm� Date Area Employee ID <br /> Grout Inspection By Date PECIAL Well Permit <br /> Pump Inspection By(� Date 1�`>. `, WAIVER Received <br /> Sail Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Chec /Amount Permit/ <br /> Info B as miffed ate Service Re vest# Invoice# Well ID# <br /> <<J7 <br /> t� 2 <br /> EHO 43-06 8101/16 WELL/PUMP PERMIT <br />