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WELL/PUMP PERMIT -= 1V 1 LETED <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 /> rn <br /> JOB ADDRESS CITY/ZIP m <br /> CROSS STREET A N O PARCEL SIZE%L 1' -*ID USE APPLICATION# <br /> OWNER NAME D •�S PHONE C/�J� �//'J <br /> tn/ <br /> OWNER ADDRESS /� ITY/STATE/ZIP ^—�,/, 9.313/�`�y� <br /> CONTRACTOR /�D L✓�✓ PHONE <br /> �/CPO?— ;Z/ <br /> 14 <br /> CONTRACTOR ADDRESS 120 ` ! CD KL/ CITY/STATE/ZIP [J6j_ 4 lA J <br /> SUBCONTRACTOR/CONSULTANT 41 PHONE 14 <br /> SUBCONTRAC R/CONSULTANT ADDRESS CI /STATE/ZIP <br /> LICENSE C-57 I C-61 I I D-09 1 Other NUMBER EXPIRATION DATE <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE i Domestic/Private `y�lrrigation/Agricultural Industrial ii Water Quality Monitoring 11 Soil Sampling/Characterization <br /> I Public Water SI m <br /> If different from Owner: Water System Name Contact Name or Phone Number rl <br /> T <br /> TYPE OF WORK J New Well I I Replacement Well i I Well Alteration/Modification ❑ Other <br /> Monitoring Well(s) #of wells ❑ Soil Boring #of borings s) Ll Geotechnical of Geotechlpcal pP�rings <br /> n <br /> i 1 Out-Of-Service Well IJ Out-Of-Service Well Renewal 11Cross-Connection Repair J I- ? ?O <br /> ❑ New Pum ump Replacement ❑ Pump Repair ❑ Raise Well CasingSq <br /> WELL CONSTRUCTION AEWV IN�+ <br /> Drilling Method 0 Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool Push Point I Other HSA(TH p N �NMOTU <br /> Proposed Well Depth ft Excavation in diameter U Open Bottom - Ci Gravel Pack/Gravel Size in-di�amr�t <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched - Steel r_7 Plastic Stainless Steel ❑ Other <br /> Grout Seal Depth it ❑ 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 i_; Free Fall !I Other F_ Retardant/Accelerator(name) <br /> PEDESTAL Installed By - Driller Pump Contractor D Other <br /> C; Concrete Pedestal❑Dimensions:Width ft Leng h ft Thick in ❑ Christy Box I Stove Pipe <br /> PUMP IV Submersible❑ Turbine C, 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 /> CURREAND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORK S COMPENSATION S. <br /> M I(VI 8 CE- O ICE REQUIRED F NSPEC IONS -PLEASE CALL(209), -7 <br /> SIGNED �1 TITLE DATE <br /> W'j%VV <br /> 01 <br /> TM NT �ENLY <br /> Application Accepted By Date Area I_ Employee ID#q� <br /> Grout Inspection By ,/ C - Date SPECIAL Well Permit <br /> Pump Inspection By � 5�`r(�GL =X1 eX� Date �� WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/o s Info B emitted Date Service Request# Invoice# Well ID# <br /> 411 01 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />