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f <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 www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> I Ln <br /> 1 `Z CITYIZIP m <br /> JOB ADDRESS j�I 5 �, C V1C K cQ 1� reL 953 D <br /> CROSS STREET APN ���CJCJ•� C PARCEL SI2C)-42(,0 LAND USE APPLICATION# 0 <br /> 42 <br /> OWNER NAME I fs�Al/1,t! �U� PHONE - V <br /> OWNER ADDRESS tS� �r 'e�L►ti �� � CITY/STATE/ZIP �Lvoe', 'CA %766' <br /> CONTRACTOR LuIIS SLI ��{PHONE �1�` L GI )9� <br /> CONTRACTOR ADDRESS + CITY/STATE/ZIP /V dd-y-s / / col fls75-1 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE XC-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE 44-30-2-1 <br /> BILLING PARTY: ❑OWNER IJ CONTRACTOR LI SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑ General Mineral/Coliform Bacteria(4391)C1 Dibromochloropropane(4392)I i Arsenic(4393) <br /> INTENDED USE XDomestic/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 Phone Number <br /> TYPE OF WORK New Well XReplacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump D Pump Replacement ❑ Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodxMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth2 ZO_ft Excavation Z. 0 in diameter ❑ Open Bottom X Gravel Pack/Gravel Siz in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 2,C1C,> ❑ Steel YPlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth /d O ft ❑ Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement sack mlx/7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ DrillerPump Contractor ❑ Other <br /> ❑ Concrete Pedestal El 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 /> M =URDVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 953-7697A <br /> SIGNED TITLE /.d 1"V•rIG DATE <br /> 4 <br /> MENT <br /> 1 � <br /> SAN J6AC UiN C U <br /> N IRONIMEPT <br /> 7 <br /> ARTMENT USE/ ONLY <br /> c� <br /> Application Accepted By i Date Z 6 I r Area�� Employee ID# _Pe-Y t c� <br /> Grout Inspection By Wk) Date [,_1 SPECIAL Well Permit <br /> Pump Inspection By Date CI WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth l S5-ft� <br /> COMMENTS <br /> -J h;n d <br /> PE SC Received Check#/ AmountPermit/Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> 0 H <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />