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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 Cw <br /> Twww.s ov.or /ehd EXPIRES 1 YEAAR FFROM DATE ISSUED <br /> JOB ADDRESS IO o6v CITY/ZIPm <br /> `A1 D <br /> CROSS STREET NN• T a APN I0�1p PARCEL SIZE 7-k VC LAND USE APPLICATION# 0 <br /> �., m <br /> Ca <br /> OWNER NAME PHONE <br /> OWNER ADDRESS \III_00 VL1VWrGL D6\/V CITY/STATE/ZIP / CaIt4y-y%tou q5� <br /> CONTRACTOR Y V\111,V1 �h PHONE 0.0i)u0q--n Do <br /> CONTRACTOR ADDRESS 1` 1/ n�,n !_/IVY '1�Vr/�� CITY/STATE/ZIP CeJ(���� 1/ YV/IC� <br /> SUBCONTRACTOR/CONSULTANT - �1�C/ X e0-ft CM, Irv& `�+ PHONE W!! ! }�8 2 ZC <br /> SUBCONTRACTOR/CONSULTANTADDRES-1400 Shoye11 car. S�I�{ `C CITY/STATE/ZIP 1{/1►� 621) y�,If'nll ✓Z19 <br /> LICENSE '4 C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER-1Z EXPIRATION DATE 9 I ',/y I Zy <br /> BILLING PARTY: D OWNER ❑CONTRACTOR I.SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:11 General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ 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 ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> D Monitoring Weli(s) #of wells ❑ Soil Boring(s) #of borings Geotechnical #of borings <br /> ❑ Out-Of-Service Well D 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 10-15' 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 10-1 T' ft S Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped )If Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal DDimensions:Width ft Length ft Thick in D Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ 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 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 /> IMUM 48 HOURADVANCE NOTICE REQUIRED FOR <br /> !INSPECTIONS-PLEASE CALL(209)953-7697 ^ <br /> SIGNED TITLES ku_?I (J1��� DATE U 2 K/ <br /> r <br /> 0 <br /> H <br /> `PARTMENT �USE ONLY ��'_' Em`� <br /> Application Accepted By Date ! 7 Area S 1 ployee ID#_, <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By &-AMA u4klZ Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service <br /> QRequest# <br /> EHD 43-06 6/11/2019 -_---/�j�•��- - {��/ L��[T' WELL(PUMP PERMIT <br />