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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 yl,- � www.s ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 11751 I1W� <br /> �Qr n 1 t`!�f'a CITY/ZIP Opt c—A q5 m <br /> _( _ ^ f D <br /> CROSS STREET 1r) f- A__-0QOQ. r95S <br /> AP FJ 1 SCJ L PARCEL SIZE LAND USE APPLICATION# A <br /> J m <br /> OWNER NAME PHONE <br /> OWNER ADDRESShd <br /> CITY/STATE/ZIP _lrJ <br /> CONTRACTOR Y n IV 9 PHONE lZV hJ Dy7 J 3�U I <br /> CONTRACTOR ADDRESS 907J✓�7 � h i(2 C'• <br /> � U �) CITY/STATE/ZIP � I t6f <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP } <br /> LICENSE ,XC-57 C-61 _ D-09Other NUMBER wvi ciEXPIRATION DATE ��3 I ZG z 1 <br /> BILLING PARTY: -OWNER YC/ONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391)I: Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE - Domestic/Private L Irrigation/Agricultural Industrial Water Quality Monitoring V 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 /> Monitoring Well(s) #of wells V Soil Boring(s) �E; #of borings ✓Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION / <br /> Drilling Method �C Mud Rotary - Air Rotary )Auger Cable Tool _ Push Point - Other <br /> Proposed Well Depth 10—,050 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 ft Neat Cement(94 Ib bag/5-10 gal water) _ Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method _ Pumped Free Fall - Other - Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller i Pump Contractor Other <br /> Concrete Pedestal -Dimensions:Width ft Length ft 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 /> MIN UM 4MH <br /> ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE(,Q2h-61rrll Z rY1 DATE <br /> v <br /> I r <br /> 1 <br /> A UI CoUNTY <br /> N IR N E AI. <br /> MWE NWT <br /> ARTMENT SE ONLY <br /> Application Accepted By Date 2 Area I Employee ID# � <br /> Grout Inspection By Date C SPECIAL Well Permit <br /> Pump Inspection By Date I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received ec Amount ate Permit/ Invoice# Well ID# <br /> Codes Info B f Remitted Service Re uest# <br /> L w <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />