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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468.3420 <br /> NON-REFUNDABLE PERMIT A CALL 209 953-7697 FOR INSPECTIONS EXPIRE 1 YEAR FROM DATEISSUEDISSUED <br /> l�} CITY/ZIP E.SGA A✓l 9�3 2,0 <br /> JOB ADDRESS ~ <br /> m <br /> D <br /> CROSS STREET APN PARCEL SIZEJFLAND USE APPLICATION# A <br /> m <br /> OWNER NAME !� V PHONE in <br /> OWNER ADDRESS A/ Ve .4 Cln/STATE/ZIP 7 CQ D <br /> (w <br /> CONTRACTOR 1�/,1 1 . .—L111 ,Y/ PH/O/jJE A� <br /> CONTRACTOR ADDRESSI?n Q� s� y CITY/STATE/ZIP /(�+ e'7' 9dr3 b�0 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/S <br /> TAT <br /> E/ZIP A <br /> LICENSE rE-57 C-61 D-09 Other NUMBER 4/- .rr.J ExPIRATION DATE �J�/►4' f <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Ldrrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Ovmer: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK (/IQew Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Wells) #of wells Soil Boring(s) #of borings Geotechnical ft 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 Atru'd Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth 4/& it Excavation_1 q in diameter Open Bottom Gravel Pack/Gravel Sizein diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter/6 in Thickness/Gauge/ASTM Sched ICY AoMeel Plastic Stainless Steel Other <br /> Grout Seal DepthQfd _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 6.-ftmped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller C_Rump 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 C RTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN C NTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENTD ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS OMPENSATION LAWS. <br /> MIMU U DVANCE NOTICE REQUIRED FOR INSPECTI(C�j�//"SS PLEASE CALL(209)953-7697 <br /> SIGNED TITL� AA., f-• DATE I PAYMENT <br /> CEIVED <br /> L 16 2019 <br /> IRAQUIN COUNTY <br /> IRONMENTAL <br /> H DEPARTMENT <br /> TMENT US OILY <br /> Application Accepted By Date / Itt,601Area mplo�ID# <br /> Grout Inspection By Date ECIAL Well Permit <br /> Pump Inspection By Date AIVER Received <br /> Soil Boring Ins ction By Date Constructed Well Depth 0 ft <br /> COMMENTS r <br /> x@6,3 <br /> OC <br /> E SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> de Info B Cash Remitted Service Re uest# <br /> ! 1 <br /> Pr <br /> "SSD. I 9 <br /> EHD 4306 revised 4114/18 �r,� - -73 71351 <br /> 1n1 WELL/PUMP PERMIT <br />