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WELL/PUMP PERMIT 1 77, <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> ? <br /> JOB ADDRESS I BOJ ,(1-GSL CITY/ZIP m <br /> � D <br /> CROSS STREET GyI I r r t pn APN OPARCEL SIZ LAND USE APPLICATION# o <br /> A <br /> /` m <br /> OWNER NAME bale yc"^�'' 6(DAtiIQP,Af i� PHONE X09 . 559. <br /> OWNER ADDRESS ZIU03 �1(,tCk- 1DnL �Ay.,• CITY/STATE/ZIP R160r\ r./�' 453(D(D <br /> CONTRACTOR { Al eA I-( t l �A,At�PHOINE �Dr•.039. 6 q.� <br /> CONTRACTOR ADDRESS ISI D S G CITYISTATE0P-/v�Ay\TP_CG r C r g53310 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS / CITYISTAT-E1IZZZII/P_ ^� <br /> LICENSE I C-57 I.�C-61 11 D-09 I Other C)V1� JV NUMBER ! �/ (W EXPIRATION DATE �D/.r) <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural a Industrial 1 Water Quality Monitoring CI Soil Sampling/Characterization <br /> IJ Public Water System E /Lz <br /> II different from Owner. Wafer System Name Contact Name or Phone Number <br /> TYPE OF WORK E New Well 0 Replacement Well ❑Well Alteration/Modification I Other A; i <br /> D Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings Geotechnical #of borings id 8 2019 <br /> D Out-Of-Service Well 0 Out-Of-Service Well Renewal I Cross-Connection Repair y <br /> New Pum LI Pum Replacement 0 Pum Repair 1-Raise Well Casing �A N AQUIN <br /> UAITY <br /> WELL CONSTRUCTION EA 7;f <br /> ROOM Co <br /> Drilling Method 1 Mud Rotary Air Rotary Auger D Cable Tool D Push Point 1 I Other EA DepAR7.NT <br /> Proposed Well Depth 20h t ft Excavation in diameter I Open Bottom I Gravel Pack/Gravel Size in diameter <br /> I i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched I Steel D Plastic Stainless Steel r Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) D Sand Cement sack mixt gal water <br /> Bentonite(20%solids) I i Other <br /> Grout Placement Method ❑Pumped O Free Fall I Other r:Retardant/Accelerator(name) <br /> PEDESTAL Installed By C Driller )<Pump Contractor I Other <br /> Concrete Pedestal(.:Dimensions:Width ft Length ft Thick in C Christy Box 0 Stove Pipe <br /> f PUMP X Submersible❑Turbine 1. Other HP_&_ Pump Set___Z_D_ft Standing Water Level er 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 /> MINI j481 R/✓/�CE NOTICE REQUIRED FOR <br /> ^INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE <br /> P"A TMENT E O L ���f <br /> Application Accepted By Date Area Employee ID#a�H/ <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By f\-Qt\M �Date v ;�4,1'VAN WAIVER Received <br /> Soil Baring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/Co Info B ash emitted Date Service Request# Invoice# Well ID# <br /> EHD 4306 &01116 O wr-i i IN 11r Pr—T <br />