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S 7 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NONIRFFUNDAEILE PERMIT www.sjgov.cirg/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> �g r� �J -J N <br /> T <br /> J 1 A o & CITYIZIP�7 / m <br /> CROSS STREET APN,27 v it)0 ��`�3 PARCEL SIZE LAND USE APPLICATION# A <br /> m <br /> OWNER NAME //\\ y� r PHONE y <br /> OWNER ADDRESS _6' /7sI <br /> CITY/STATE/ZIP �j <br /> CONTRACTOR `'h d ,}y� ��v) cPHONE y1?, �/' 'S L���[+ <br /> CONTRACTOR ADDRESS / r19 1- f V/ S'f C1/STATE/ZIP ✓t - vin L./C� /J(i <br /> SUBCONTRACTOR/CONSULTANT V ) ® PHONE ZUG r~ U0 <br /> 7 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS i �-, �� ✓fir J �CCITTYIS'�TAATrE�IZIP 4 `� qS6- ` <br /> I'� <br /> LICENSE C-57 r C-61 D-09 Other NUMBER [Civ r V EXPIRATION DATE V ZQ O <br /> BILLING PARTY: _i OWNER 4`CONTRACTOR - SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:-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 O—er. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK i New Well Replacement Well Well Alteration/Modification i Other <br /> i Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical�#of borings <br /> Out-Cf-Service Well Out-Of-Service Well Renewal u Cross-Connection Repair <br /> New Pum i Pump Replacement iI Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ". Mud Rotary -Air Rotary Auger i!Cable Tool ]Push Point L, Other <br /> Proposed Well Depth IS'7e,5 ft Excavation in diameter C Open Bottom C Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad r Steel r Plastic 7 Stainless Steel I Other <br /> Grout Seal Depth ft 4 Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement MethodN/Pumped Free Fall -1 Other -Retardant/Accelerator(name) <br /> PEDESTAL Installed By - Driller Pump Contractor - Other <br /> Concrete Pedestal Dimensions:Width It Length It Thick in Christy Box =Stove Pipe <br /> PUMP Submersible:=Turbine Other HP 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 /> ,M///I111yN�..I/M,UM'48 O R ADVANCE NOTICE REQUIRED FOR,�'/jN��SPr-',CTIIQNSC,-PLEASE CALL(209)9 -7669 /{ <br /> SIGNED �/yy�/r TITLE .�I(Il1 `�/ P cr DATE ! �/ <br /> HENT <br /> EIVED <br /> -29 2019 <br /> kC UIN COUNTY <br /> IIC MENTAL <br /> L H PARTMENT <br /> r ARTMENT UE ONLY <br /> ¢. <br /> Application Accepted By Date l AreaEmployee ID# <br /> Grout Inspection By Date 'SPECIAL W II Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By kajkeu— Date Constructed Well Depth tt <br /> COMMENTS <br /> PE SC Received Check#I Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitteo Service Re e # <br /> WV <br /> 41* <br /> EHD 43-06 6/1112019 WELL/PUMP PERMIT <br />