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J <br /> 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 p www.s ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Z -ToeS CITY/ZIP J 11 Q S 3 m <br /> -719 0 <br /> CROSS STREET J�' TOYIjn APN PANRCE/1L SIZE3L).�`Y LAND USE APPLICATION# p <br /> OWNER NAME b�"/ / GPHrONE N <br /> OWNER ADDRESS J Ur/(-� �(� CrrY/STATE2IP Ce �/{'6 <br /> CONTRACTOR 1 Y- }rte {� �,/�L CPHHONNE ! �� <br /> CONTRACTOR ADDRESS Z�J{J ` ,�~"lr II f J�E- 1L CITY/STATE2IP J"c C� -S <br /> SUBCONTRACTOR/CONSULTANT T W PHONE � t 00 <br /> SUBCONTRACTORICONSULTANT ADDRESS 3 CrrY/STATEIZIP <br /> LICENSE ,/C-57 C-61 D-09 Other NUMBER 77 EXPIRATION DATE 10 to <br /> BILLING PARTY: 'OWNER ✓CONTRACTOR _ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)-Dibromochloropropane(4392)-Arsenic(4393) <br /> INTENDED USE IDomestic/Private 7 Irrigation/Agricultural - Industrial -Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Ov ner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK i New Well 1 Replacement Well Well Alteration/Modification i i Other <br /> I Monitoring Well(s) #of wells F Soil Boring(s) 4 of borings VGeotechnical otbodngs <br /> Out-Of-Service Well Out-Of-Service Well Renewal a Cross-Connection Repair <br /> -_I New Pum .l Pump Replacement ❑Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method I Mud Rotary Air Rotary 'Auger Ci Cable Tool - Push Point ❑ Other <br /> Proposed Well Depth ?-� _ft Excavation in diameter 1- Open Bottom F Gravel Pack/Gravel Size in diameter <br /> I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thicknes /Gauge/ASTM Schad C Steel C Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) F Sand Cement sack mix/7 gal water <br /> I Bentonite(20%solids) Other <br /> Grout Placement Method JPumped 1 Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By : Driller Pump Contractor - Other <br /> Concrete Pedestal❑Dimensions:Width ft Length ft Thick in . Christy Box G 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 /> MINIMUM 48 ADVANCE NOTICE REQUIRED FOR INSP TIONS-PLEASE CALL(209)95 -7697 <br /> SIGNED TITLE C�-a � rr/�l�eer DATE / G <br /> y4f, <br /> F�VFO <br /> � 2419 <br /> c <br /> IPA <br /> A Nry <br /> NT <br /> E<P lit— <br /> M EE O L <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 B Date h Constructed Well Depth ft <br /> cQVMENTS <br /> PE SC tReceived Check#/ Amount ate Permit/ Invoice# I D <br /> Codes Info By Cash .Re itte Service Re uest# <br /> I <br /> EHD 43-06 611112019 L'{• 02 Y Y f WELL(PUMP PERMIT <br />