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1 <br /> e <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 /> / <br /> Ln <br /> ADDRESS 44-a 4 V-;C-44 1%6 4- (=p b CITY/ZIP�'4 m <br /> Z2I 090-( D <br /> S <br /> CROSS STREET `ryf �}N t4-or- APN22-1—ofa ^ 2od�r+"'1PARCELSIZE/.?,.r7 LAND USE APPLICATION# <br /> �I I m <br /> ( <br /> OWNER NAME YL1} //�/1 F�L�� ZMPIPV �X I"C l PHONE t ? ria <br /> OWNER ADD01ESS ZZ 1 t-63 f t&4J�+ 4,.,c- _ CITY/STATE/ZIP 444,—teem-� of �J9513/7 <br /> CONTRACTOR �jt��tr�-/}LG '"�CtiL/�- "I004-1411ed PHONE (')"W <br /> 772c-//Y7gy <br /> CONTRACTOR ADDRESS�OSD �NOriftZl�C Avlj CITY/STATE/ZIP W-fA-C CA kll /Z <br /> BCONTRA /CONSULTANT �l)�G6� El)IYf Il GEO 'IESY(1i If /'VC . PHON 71Y yy��-Jr, 2-f <br /> SUBCONTFZACTO ONSULTANTADDRESS 1Sy /VOiy.Lrf ff,*ON J--'r CITY/STATE/ZIP IP/A#WK (�af 7ZG"67 <br /> LICENSE 57 ❑ C-61 r] D-09 ❑ Other NUMBER fl9 EXPIRATION DATE <br /> BILLING PARTY: OWNER IXONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) , Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring KSoil 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 C l- X-2- <br /> -1 <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical_ #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal D Cross-Connection Repair <br /> ❑ New Pump U Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool N 'ush Point ❑ Other <br /> Proposed Well Depth SO ft Excavation in diameter ❑ Open Bottom 11 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 LI Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth 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 (Other T'Le�O14 F LI Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal DDimensions:Width it Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine ❑ Other 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 /> M M 48 H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209)953-7697 <br /> SIGNED_ _ TITLE �"v�K DATE�1� <br /> �r <br /> a <br /> r <br /> DE AR- U� E /ONLY_T <br /> Application Accepted By Date <br /> Area mployee ID# <br /> Grout Inspection By _ Date SPECIAL Well Permit <br /> Pump Inspection By A A ADate WAIVER Received <br /> Soil Boring In action By Dateja Constructed lyw11 Depth _ _ft <br /> COMMENTS <br /> Ar <br /> PE VSC Received Checl Amount Date Permit/ Invoice# Well ID# <br /> ,C,oqps Info B ---C"aish Re fitted Service Request# <br /> Q <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />