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;,/q 1(6 t 32 <br /> ' 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 CITY/ZIP m <br /> +� D <br /> CROSS STREET I�c,✓ L G��. APN PARCEL SIZEC�LAND USE APPLICATION# <br /> 11 m <br /> OWNER NAME 1�c 1c� L� ��2 �C V O 15�y i t_ PHONE CO) <br /> OWNER ADDRESS ,M�V!! ^^ CITY/STATE/ZIP <br /> CONTRACTOR �t / (-i 1 (� A, s.- oan PHONEA( Z�ti 3b 7-3'3Oi <br /> CONTRACTOR ADDRESS G(62 CITYISTATE/ZIP L�' Cif qT 7-LtU <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATE/ZIP <br /> LICENSE )k C-57 C-61 - D-09 _ Other NUMBER C'Cr`ICC'-1 EXPIRATION DATE 5 ' 31 ZOZI <br /> BILLING PARTY: -OWNER ONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)C Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE - Domestic/Private L_ 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 a Replacement Well ❑ Well Alteration/Modification Other <br /> ❑ Monitoring Well(s) #of wells C Soil Boring(s) #of borings Y Geotechnical (_Q #of borings <br /> ❑ Out-Of-Service Well I Out-Of-Service Well Renewal i i Cross-Connection Repair <br /> ❑ New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method - Mud Rotary Air Rotary X Auger Cable Tool - Push Point - Other <br /> Proposed Well Depth I.."-I ft Excavation Coy 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 IStainless Steel - Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method C Pumped - Free Fall ❑ Other - Retardant/Accelerator(name) <br /> PEDESTAL Installed By - Driller Pump Contractor Other <br /> Lj Concrete Pedestal L7 Dimensions:Width ft Length ft Thick in - Christy Box _J Stove Pipe <br /> PUMP - Submersible❑ Turbine 1 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 /> MINIMUM 4 HOURANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED f 7V TITLE DATE el 1'1'7-0*0'1 <br /> S A UNO N <br /> EN 11HUNIVIL <br /> F�H _T-_ <br /> ARTMENT U E ONLY <br /> Application Accepted By Date Z Area mployee ID# <br /> Grout Inspection By Date C S ECIAL Well Permit <br /> Pump Inspection ByDate 1 I WAIVER Received <br /> Soil Boring Inspection By A �UkO. Date D Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Remitted Service Re uest# <br /> /s o (111. c We00q0 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />