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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.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS lyyi'% (N �Inwk �� CITY/ZIP oLktu.� c)52C( m <br /> D <br /> CROSS STREET /hy � A 1 �APN C L PARCEL SIZE LAND USE APPLICATION# A <br /> OWNER NAME ,o` ��(/� �rU E� (n ,p-c /j� PHONE <br /> OWNER ADDRESS 7 O PA �7/`6 +' Z CITY/STATE/ZIP �r Z 61 �FJ <br /> CONTRACTOR Ak, 1 �n�j rj�� l� TQr'(��LL PHONE <br /> CONTRACTOR ADDRESS `ZG 2 C.�a <°�t r- \ i V w CITY/STATE/ZIP IL"( (A CA S-2_ l Q <br /> SUBCONTRACTOR/CONSULTANT PHONE C w <br /> SUBCONTRACTOR/CONSULTANT ADDRESS k .0 -y CITY/STATE/ZIP <br /> LICENSE F�KC-57 ❑ C-61 ❑ D-09 _ Other NUMBER (,L.,YVC'`I EXPIRATION DATE ''S 3i L <br /> BILLING PARTY: L OWNER CONTRACTOR _ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)I Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE _ Domestic/Private ] Irrigation/Agricultural Industrial _ Water Quality Monitoring I 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 /> _ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings 4 Geotechnical #of borings <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump -i Pump Replacement r, Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method F Mud Rotary ❑ Air Rotary YAuger - Cable Tool _ Push Point Other <br /> Proposed Well Depth ft Excavation 14�-C in diameter 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 Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth i 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 _ Pumped Free Fall ther Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller [I Pump Contractor Other <br /> _ Concrete Pedestal ]Dimensions:Width ft Length ft Thick in Christy Box L 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 /> A <br /> MININIVIVI 48 HOUR APVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED r L✓ TITLE �L'( YI�L �� /° ZI�SrEi DATE <br /> c <br /> 4A W <br /> SAO .1 <br /> J <br /> VST <br /> E® <br /> q 019 <br /> .4 <br /> T � <br /> NT. <br /> PARTMENT U E N L Y <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date PECIAL Well Permit <br /> Pump Inspection By Date I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By- as Remitted Service Request# <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />