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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.orq/ehd It EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 41' /� {+ CIIY/ZJP -S M <br /> A� D <br /> CROSS STREET APN PARCEL SIZE D USE APPLICATION# z <br /> � m <br /> OWNER NAME QV 5 r0 Ir PHONEAO "Q"1 <br /> OWNER ADDRESS `r l �T''O L CITYISTATE17JP Q .{ <br /> CONTRACTOR 'D L., G <br /> PHONE ! <br /> CONTRACTOR ADDRESS 2 r/�f CIT//STATE/LP Lo d&'�Gw 9af <br /> SUBCONTRACTOR/CONSULTANT �— PHONE r^ <br /> SUBCONTRACTORICONSULTANT ADDRESS CRY/STATEIZIP <br /> �,.,�� <br /> LICENSE �-57 LI C-61 ❑D-09 ❑ �f�/�r�'Other NUMBER� N E%PIRATION DATE <br /> BILLING PARTY: ❑OWNER ❑CONTRACTOR ❑ 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 Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> L Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings 11Geotechnical #of borings <br /> ❑Out-Of-Service Well Out-Of-Service Well Renewal fl Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth It Excavation in diameter L 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 ❑Steel C Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) C Sand Cement sack mixl7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length It Thick in L Christy Box L Stove Pipe <br /> PUMP ❑Submersible Turbine ❑Other HP-Y&P Pump Set It Standing Water Level R <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 /> MINIMU�IIJR ADVANCE NOTICE 13EQUIRED FOR INSPE TIONS-P EASE CALL(209)953-7697 <br /> �~- SIGNED �� _�/ TITLE DATE J <br /> PAYMENT <br /> RECEIVED <br /> AUG 15 2019 <br /> JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> 1` HEALTH DEPARTMENT <br /> D PARTME-N E ONLY <br /> Application Accepted By Date Area <br /> �4SPECI Employee ID#��— <br /> Grout Inspection By Date ellPermit <br /> Pump Inspection Bykfts� Date �� ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B a Remitted Service Re uest# <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />