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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 PALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Lh <br /> JOB ADDRESS �7 O W• /� t CI7Y/ZIP_ m <br /> t D <br /> CROSS STREETS APN ' 7 G PARCEL SIZE LAND USE APPLICATION# o <br /> _ A <br /> /� m <br /> OWNER NAME ?R�c;f�' ,/,ft ?PHONE ��/� 9�yy o+ <br /> OWNER ADDRESS L CITY/STATE/ZIP / <br /> CONTRACTOR62 /• A;i d. NE sI G <br /> CONTRACTOR ADDRESS 300 L57, O CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE, - • <br /> SUBCONTRACTOR ADDRESS /CIITTYISTATE/ZIP 4� q <br /> LICENSE ,,C; ( I C-61 D-09 I Other NUMBER 7�/ SI� d ExPIRATION DATE �� ✓ �• <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USEmestic/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 1►few Well C.Replacement 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 i Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method C­MUd Rotary Air Rotary �Auger Cable Tool Push Point Other <br /> Proposed Well Depth%I C—Qft Excavation /2,*in diameter Open Bottom Gravel Pack/Gravel Size 6 in diameter <br /> Conductor Casing in diameter / Conductor Casin Depth ft <br /> Well Casing Diameter�in Thickness/Gauge/ASTM Sched IOJ R 27 Steel I—PfMic -i Stainless Steel J Other <br /> Grout Seal Depth /OQLft ❑Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mW7 gal water <br /> L_5entonite(20%solids) ❑Other <br /> Grout Placement Method Pumped Free Fall i Other Retardant/-Accelerator(name) M <br /> PEDESTAL Installed By i Driller Pump Contractor er A�MENT <br /> Concrete Pedestal i Dimensions:Width ft Length ft Thick in I:i Christy Box ❑Stove Pipe l�ZECEIVED <br /> PUMP 4.6ubmersible Turbine her HP Pump Set It Standing Water Level ft v Y <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN 2019 <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND CTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH p,t�,� <br /> WORKERS CO ENSATION LAWS. SANfAQUIN COUNTY <br /> MI U ADVANCE NOTICE REQUIRED FO NSPECTION PLT[�SECALL(209)953-7697 ERONMENTgL <br /> SIGNED TITLE A r tt�SJ/ DATE 7 DEPARTMENT <br /> G <br /> IV X • J U L 1 1 2019 <br /> IRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> if FV <br /> Yh <br /> DEPARTMENT USE ONLY / <br /> Application Accepted By Date Areamployee ID# <br /> Grout Inspection B Datajj4 SPECIAL W II Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspe lion By Date onstructed Well Depth ft <br /> C07M TS <br /> 0 (�, Q F <br /> PE SC Recelved Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Re uest# Invoice# Well ID#iA <br /> L 1/tJQ1� <br /> EHD 43.06 revised 4/14/18 WELL/PUMP PERMIT <br />