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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468.9420 <br /> NON-REFUNDABLE PERMIT www.sjqov.Or Iehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS y��^ Q 0 S. -!c Lt�L►V�y Ty CITY/ZIP n `i\" r"ipS,J/y� �L� bmDD <br /> CROSS STREET Ci �- APN 1 `4J-�(r 1 I PARCEL SIZE LAND USE APPLICATION# V f� v <br /> OWNER NAME <br /> L13A r'Jbl� 1` V 1-`V PHONES 41-< Y <br /> OWNERADDRESS � - ib1 �4V" H'�C G�CrrY/STATE/ZIP ]�IrL'tW.:.� 1�(l�✓l �✓,,�y <br /> CONTRACTOR y�uL1� \uJ�L`k 'ok k-L�'7v C�t�}�l..�i PONE 44 <br /> CONTRACTOR ADDRESS �./� / CITY/STATE/ZIP �Yr7 �I <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CIY/STATE/ZIP <br /> LICENSE I?(C-57 F C-61 n D-09 -1 Other NUMBER�k'S9 EXPIRATION DATE <br /> BILLING PARTY: ❑OWNER CONTRACTOR 7 SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE 7 Domestic/Private ❑Irrigation/Agricultural C Industrial ❑Water Quality Monitoring ',Soil Sampling/Characterization ` <br /> 7 Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK I New Well i i Replacement Well i Well Alteration/Modification i i Other <br /> # boon s <br /> -1 Monitoring Well(s) #of wells CSoil Boring #of borings of s)_ _ �[Geotechnical �I <br /> -j Out-Of-Service Well Out-Of-Service Well Renewal a Cross-Connection Repair 1 f <br /> C New Pum 7 Pum Replacement 13 Pump Repair L1 Raise Well Casing +V 214, <br /> WELL CONSTRUCTION <br /> Drilling Method 7 Mud Rotary ❑Air fotary Auger ❑Cable Tool 7 Push Point ❑ Other PAY/if <br /> Proposed�fEll Depth 'S7 ��Excavation in diameter C Open Yt en Bottom C Gravel Pack/Gravel S(ze in diameter <br /> �.. 7 Conductor Casing in diameter / Conductor Casing Depth ft vc <br /> Well Cas ng Diameter_in Thickness/Gauge/ASTM Schad C Steel C Plastic 7 Stainless Steel ❑Other o <br /> Grout Seal Depth ft x Neat Cement(94 Ib bag/5-10 gal water) C Sand Cement sack mix/7 gal water skP Q <br /> -1 Bentonite(20%solids) n Other U 2 90 <br /> Grout Placement Method n Pumped -1 Free Fall -1 Other -1 Retardant/A elerator(nae) ✓O IQU O•,/ <br /> PEDESTAL A//� Installed By ❑Driller C Pump Contractor ❑ Other Ty&0A( COU, <br /> /Y/7 7 Concrete Pedestal❑Dimensions:Width it Length ft Thick in ❑Christy Box ❑Stove Pipe p�pgR�TA� •r <br /> PUMP kILI 7 Submersible❑Turbine ❑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 /> INIMUM 48 HOUR ADVANCE NOTICE REQUIRED FO NSPECTIONS/-.,PLEASE CALL(209)99L53-76(997 <br /> SIGNED <br /> TITLE � �V-fid f./�L'` lL�1 DATE `V� ( I <br /> „ B-7 It rt . I I B-2 L <br /> - -{ ♦ II <br /> 5 <br /> 7 <br /> I J I -I I - <br /> �Zo I <br /> B-3 <br /> El_, <br /> -s � I s <br /> No <br /> + PROPOSED TEST BORING LOCATION <br /> I <br /> `6 TT l LLLL B-1 <br /> a> <br /> P TMENT ujrE O LY <br /> Application Accepted By� ate Area_ mployee ID# <br /> D t ❑ S' PECIA��Permit <br /> Grout Inspection By a e <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By L"-Lk/ Date 0 L4 I cl Constructed Well Depth ft <br /> COMMENTS PLY Yt/11' -eiy\L U21 & L9&Y vl Vt 0 t'(UA <br /> PE Sc Received Che Amount 0. ate Permitt Invoice# Well ID# <br /> odes Inf sh emitted Service Re uest# <br /> i <br /> EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />