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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR r+J�[y ,/nom 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> ' NON-REFUNDABLE PERMIT J 7V rP�WWW�r /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> L rn <br /> JOB ADDRESS D �(' 0 �'D►'t CITY/ZIP In <br /> D <br /> CROSS STREE =17 <br /> APN PARCEL SIZI� Q� LAND USE APPLICATION# v <br /> `' GG• m <br /> OWNER NAME .L,�PHO,,N�E� C7l `f _ rn <br /> OWNER ADDRESS gg&11—�crnc y� ��• �{ CITY/STATERIP +k6'�� <br /> CONTRACTOR 1/1 ' ei g4 L L LPHONNE_,' <br /> ♦� <br /> CONTRACTOR ADDRESS �1_ YQQf'T \6V CIN/STATE/ZI <br /> /J��-I&4 <br /> SUBCONTRACTOR/CONSULTANT ♦ ,,��I tc'1,ri,i..0 PHONE <br /> SUBCONTRACTORRICONSULTANT ADDRESS CITY/STAT�EIZIP - <br /> LICENSE t<'57 0 C-61 0 D-09 0 Other NUMBER 170�n�J EXPIRATION DATE <br /> BILLING PARTY: D OWNER %?<ONTRACTOR G SUBCONTRACTOR/COONSSUULT1A_NT� <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)D Arsenic(4393) <br /> INTENDED USE D Domestic/Private 0 Irrigation/Agricultural C Industrial 0 Water Quality Monitoring oil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK D New Weil ❑Replacement Well 0 Well Alteration/Modification D Other � 94 <br /> 0 Monitoring Weli(s) #of wells D Soil Boring(s) #of borings S eotechnical s of borings <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement :1 Pump Repair L Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary C Air Rotary W<uger D Cattle Tool C Push Point C Other <br /> Proposed Well Depth 5k It Excavation in diameter 7 Open Bottom i Gravel Pack/Gravel Size in diameter <br /> i i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad 7 Steel 7 Plastic D Stainless Steel 0 Other <br /> Grout Seal Depth ft V eat Cement(94 Ib bag/5-10 gal water) -1 Sand Cement sack mix/7 gal water <br /> D Bentonite Pu�(20.%solids) C Other <br /> Grout Placement Method l3' mped C Free Fall D Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br /> U Concrete Pedestal UDlmenslons:Width ft Length It Thick in L Christy Box L Stove Pipe <br /> PUMP i i Submersible I Turbine i 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 /> MINIMU 48 R ADVANCE NOTICE REQUIRED FOrR1INS�ftECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE�i�7��n,T�.G.r DATE it/ K41 <br /> �Nx <br /> o % o(}19 <br /> FpgRT���T y <br /> FNT <br /> RIF ENT US ON <br /> Application Accepted By Date Areaj_j� Employee ID#(4jj! W <br /> Grout Inspection By Date ❑ PECIAL Well Permit <br /> Pump Inspection By Date T q ❑ WAIVER Received <br /> Soil Boring Inspection By LAVOWOt Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted, Date Service Request# invoice# Well ID# <br /> 4&411WrooA-01 11-- <br /> A <br /> z <br /> EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />