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c cK -* (07y <br /> WELUPUMP PERMIT jj <br /> RUM <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT �) CALL 209 9\53-7697 FOR INSPECTIONS 1 EXPIRES 11 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1�9y'�n l/� � �y, / CrrYIZIP <br /> CROSS STREET-� APN �0D-1 PARCEL SIZE LAND USE APPLICATION# n <br /> OWNER NAME PHONE �! <br /> 6Ag��� (c r�l'� <br /> OWNER ADDRESS ti CITYISTATE/ZIP / <br /> CONTRACTOR � I C- � PHONE <br /> �j � <br /> CONTRACTOR ADDRESS v1) �� CrTYISTATEhn,C/7 1,tkbi.-t�-A �!��36 1 <br /> SUBCONTRACTOR PHONE �� <br /> SUBCONTRACTOR ADDRESS CrrYISTATEJZIP <br /> LICENSE C-57 C-61 1 D-09 q Other NUMBER C� � EXPIRATION DATE 7 <br /> DOMESTIC WELL SAMPLING: _General Mineral/Coliform Bacteria(4391)a Dibromochloropropane(4392)C Arsenic(4393) <br /> INTENDED USE Domestic/Private -'. IrrigationlAgricultural ❑Industrial F Water Quality Monitoring ❑Soil Sampling/Characterization <br /> F1 Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK J New Well Replacement Well L Well Alteration/Modification i Other <br /> Monitoring Well(s) #of wells ❑Soil Boringp of borings s) l Geotechnical K of borings P <br /> ice Well [I Out-Of-Service Well Renewal C Cross-Connection RepairOervI Pump Replacement Pump Repair Raise Well Casing <br /> cei��Q � <br /> WELL CONSTRUCTION i4�f <br /> Drilling Method i Mud Rotary i Air Rotary Auger i Cable Tool i Push Point I! Other <br /> Proposed Well Dapth ft Excavation in diameter I Open Bottom L Gravel Pack/Gravel Size in djaA, 6 2olq <br /> Ll Conductor Casing in diameter I Conductor Casing Depth ft 3AN J OU PP <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched C Steel n Plastic ❑Stainless Steel r'�Other rA� (1])1J COON <br /> TY <br /> Grout Seal Depth ft Neat Cement(94 lb bagl5-10 gal water) r-�Sand Cement sack mi pr N&1CN7AL <br /> Bentonite(20I solids) i Other ART�>C <br /> Grout Placement Method Pumped _:Free Fall i. Other j Retardant/Accelerator(name) N r <br /> PEDESTAL Installed By i Driller I Pump Contractor I Other <br /> Concrete Pedestal _Dimensions:Width ft Length ft Thick in a Christy Box I Stove Pipe <br /> PUMP Submersible)Turbine 1 1 Other Z HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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. 1 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 /> MINIMLIM 48 WUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)95 -769 <br /> SIGNED __ TITLE ,/// DATE <br /> !1 <br /> PA TMENT U E O LY <br /> Application Accepted By Date Area Employee <br /> Grout Inspection By Dale L' PECIAL Weil Permit <br /> Pump Inspection By Date 2 L W C WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS - <br /> PE Sc ReceivedAmount Date Permit/ Invoice# Well ID# <br /> COOPS Info By_ E9.h fitted &ace Reituest# <br /> EHD 49--06 revised 4/14/18 WELL/PUMP PERMIT <br />