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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT „ CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> `L <br /> JOB ADDRESS 1 (b.3 E p1%,-n <br /> D <br /> CROSS STREET eC A <br /> r, A1 W,\ ,Y7 APN / PARCEL SIZE 1 LAND USE APPLICATION# Z <br /> OWNER NAME JG�C� - l.� I� PHONE Z0f4-SF5-30 kii <br /> OWNER ADDRESS { 17 J500el J / CITT/STATEMP <br /> CONTRACTOR PC,"t i C;,1 QUA MO 1 1 n r_ PHONE )LO" <br /> 111 <br /> CONTRACTOR ADDRESS X��ti C�WtY.lj �2� CrTY/STATE/ZIPxl:`GN' <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE f,C-57 C-61 -:D-09 7 Other NUMBER jL1�j EMPIRATIONDATE t 19 <br /> DOMESTIC WELL SAMPLING' General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)n Arsenic(4393) <br /> INTENDED USE 7<Damestic/Private �Irrigation/Agricultural Industrial a Water Quality Monitoring ::Soil Sampling/Characterization <br /> Public Water System <br /> Ir dieerem hom Owner. Water system Name Gonad Name or Phone Number <br /> TYPE OF WORK a New Well -i Replacement Well _Well AlterationlModification a Other <br /> Monitoring Well(s) #of wens n Soil Boring(s) #of b01ngs Geotechnical F of bomgs <br /> L Out-Of-Service Well Out-0f-Service Well Renewal a Cross-Connection Repair <br /> New Pum n Pump Replacement F.Pump Repair n Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 7 Mud Rotary ,Air Rotary :Auger Cable Tool Push Point n Other <br /> Proposed Well Depth It Excavation in diameter r Open Bottom n Gravel PatluGravet Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thidmess/GaugelASTM Sched Steel n Plastic Stainless Steel Other <br /> Grout Seal Depth It n Neat Cement(94 lb bagl5-1 D gal water) n Sand Cement sack mixf7 gal water <br /> -t Bentonite(20%solids) n Other <br /> Grout Placement Method rI Pumped f Free Fall r Other n Retardant I Accelerator(name) <br /> PEDESTAL Installed By i_i Driller $.Pump Contractor u Other <br /> Concrete Pedestal nDimensions:Width It Length ') ft Thick�-in C Christy Box ^Stove Pipe <br /> PUMP )e Submersible,Turbine ,Other HP ^�o Pump Set­_j 1:-0ft Standing Water Level �-O 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 4.a HOUF `,-DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED ? TITLE S� yl'.yL/ DATES 1 /'9/��tp �e,• <br /> W2 \\ I I I I I I A iq p5 YV <br /> 2019 <br /> G o AaurV COLJ� <br /> A ' �4ARTMEN-r <br /> Rd <br /> U <br /> _ PA fMENT U E NLY „IA/NNC,-, �, /f� <br /> /� <br /> Application Accepted By ate Area <br /> Employee IDX,4AL=ice <br /> Grout Inspection By Date_ `f U "`SPECIAL Well Permit <br /> Pump Inspection By Data�. V 11.Ce cl` 7 WAIVER Received <br /> Soil Boring Inspection/By A Date Constructed Well Depth It <br /> COMMENTS UIL L t <br /> PE SC Received Check#/ Amount Permit! <br /> Co s Info Cash emitted Date ServiceR uest# Invoice# We111D# <br /> `c �l <br /> CHD 43-06 revieeA 4/14/ta YQ�U�T 7 f1 WLLI-F UMP FERMI I <br />