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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 5232(209)468-3420 <br /> NON-REFUNDABLE PERMIT 1� www.$ Ov.GT /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> mTo`T <br /> JOB ADDRESS 320 M � �f n CIT (�/KSI <br /> /ZP tT Are-CD- 85337 m <br /> CROSS STREETAPN or_W I LI O'R(O D <br /> I I!� PARCEL SIZE I I I, LAND USE APPLICATION# A <br /> OWNER NAME S1c�J O"'^r Fla.chl`y Tr V s� v <br /> ElaNEO �elpN�C �{ �U��OW�1 PHONE <br /> OWNER ADDRESS CITY/STATE/ZJP HOo_',-N4 eC,_ � 8533 <br /> '7 <br /> CONTRACTOR PHONE 3R8-O(0-5Q <br /> CONTRACTOR ADDRESS 1-7a'7601d&I •fillet, <br /> N <br /> CITY/STATFJLP LA..- �troP Cfl 9 /$83 <br /> SUBCONTRACTORfCONSULTANT Geo -CX SU�OSuv4c-ce- PHONE q/40-799- 31.78 <br /> SUBCONTRACTORICONSULTANT ADDRESS 15/0 '- ""derv"' br CITY/ST��AttTE/ZJP bIy4n C^ �5(p'pM.6 <br /> LICENSE Ii D C-61 D-09 Other NUMBER g`"K(0'7 EXPIRATION DATE 1/ <br /> 4 X02=0 <br /> BILLING PARTY: C'OWNERCONTRACTOR SUBCONTRACTOR/CONSULTANT <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 Owner Water System Name Contact Name or Ph—Number <br /> TYPE OF WORK _ New Well Replacement Well ;I Well Alteration/Modification Other <br /> Monitoring Wells) #of weAs D Soil Boring(s) a of bonne: ✓Geotechnical 9 of borings <br /> Out-Of-Service Well 0 Out-Of-Service Well Renewal Cross-Connection Repair <br /> i New Pump Pump Replacement J Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool (Push Point Other <br /> Proposed Well Depth450 ft Excavation cZ in diameter D 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 D Steel 0 Plastic Stainless Steel Other <br /> Grout Seal Depth 50 R /Neat Cement(94 Ib bag/5-10 gal water) r,Sand Cement sack mfx17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method ✓Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Dnller 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 1 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. 1 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 /> MINIM�UpM,/488jHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> } <br /> SIGNED /ice✓Y_Y/// �/��'�- TITLE 0i x} <br /> 6-1U6/I�E�L DATE `�-a7-19 <br /> � C <br /> zb <br /> 641 <br /> �8 <br /> 9,%, <br /> O�A RFT oCNry <br /> MF'1'T <br /> PAR MENT � <br /> �JO LY - l�/t <br /> Application Accepted By Date /' Area -mployee ID#��Q'f//F�'`f4 <br /> Grout Inspection By Date SPECIAL We11 Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> r <br /> COMMENTS <br /> PE SC Received Check#! Amount PertniU <br /> o Info Cash emitted Date ervice Re uest# Invoice# Well ID# <br /> �. <br /> EMD 4J-0e 6i1112019 A _ �� /��� ��� ��qt� WELL/PVNP PERMn <br />