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f 1 <br /> WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY NVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABL PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 7 YEAR FROM DATE ISSUED Q,^ L��q,/ ,Q� /, _Ln <br /> JOB ADDRESS - G" Q , S r'! CITY/LP IJP 64X; M <br /> m D <br /> CROSS STREET t O LA. APN, —61 `W 1 PARCEL SIZE LAND USE APPLICATION# O <br /> OWNER NAME (/,' ✓I r,r' V✓`(r}7 Cy^ t- Sd'1314-4 <br /> i a© t !' w^ PHO E "�I 1✓– i b rn <br /> OWNER ADDRESS ,�J" 60)( 004 Lrr 'sn1` `J1CITY/STATE/ZJP ^ <br /> •^, <br /> CONTRACTOR Y/�`� ` PHO E • qv •_-1–L®O <br /> CONTRACTOR ADDRESS H&LG V��7 �Y - CITY/STATE/Z1 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE XC-57 _C-61 _. D-09 :_Other NUMBER O O EXPIRATION DATE 3o 20Z-z) <br /> DOMESTIC WELL SAMPLING:IS General MineraVColiform Bacteria(4391) Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE 0 Domestic/Private C,Irrigation/Agricultural '7 Industrial -�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 -Replacement Well -Well Alteration/Modification - Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of bem gs Geotechnical�#of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal C Cross-Connection Repair <br /> New PUMP L Pump Replacement Pump Repair =i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary 1 Air Rotary Auger r Cable Tool i Push Point ❑ Other <br /> Proposed Well Depth 10- Excavation-B—in diameter i Open Bottom 0 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 iC)"�ft ,kNeat Cement(94 Ib bag15-10 gal water) Sand Cement sack mixl7 gal water <br /> _!Bentonite(20%solids) Other <br /> Grout Placement Method Li Pumped Free Fall ther 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller C Pump Contractor 0 Other <br /> Concrete Pedestal EDimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible i-Turbine Other HP Pump Set ft Standing Water Level It <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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MUM 4$-HOUR ADVANCE NOTICE REQUIRED FOR INS ECTIONS,-PLEASE CALL(209)953-7697(� <br /> SIGNED TITLE �V DATE <br /> E�Nr <br /> 0� 2019 <br /> P��TAN*rY <br /> MFNT <br /> PA TMENT U E FINLY <br /> f" •N� <br /> Application Accepted By Date Area ��`_ Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date - WAIVER Received <br /> Soil Boring Inspection By If 1 14 2 _�l.b Date 7 structed Well Depth ft <br /> COMMENTS <br /> PE SC Received .10,11* Amount Date Permit( Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Re uest# <br /> EHD 43-08 revised 4/14/18 WELL/PUMP PERMIT <br />