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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 /IA EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS (�q I SOU 1 CITYILP M0*- Cc- f Cq qJfa1 r� <br /> /� <br /> �7MWD <br /> CROSS STREET �• APN 'LOB`650-GPARCEL SIZE—LAND USE APPLICATIO(N�# <br /> OWNER NAME �1 O'er <��CQ l� 1 r ry ,J PHONE 231— —1 9cJA7 rNn, <br /> OWNER ADDRESS �IAO� IOI `—Ok`�`AY1.P• ^.r�'�"IY��.\ CITY/STATE/ZIP('�N't'���/C!!j <br /> � <br /> CONTRACTOR I Y s '{�L-�L s r\khi� ZI • _ PHONE (7 ZZ.—/1�—L 2, <br /> CONTRACTOR ADDRESS_ I 16e/s `�A CITYISTATEJZIP (Y�/ ACM/_-d 4C L 4 'L <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP ( ^� <br /> LICENSE 'KC-57 ❑C-61 ❑D-09 ❑Other NUMBER 4%2- EXPIRATION DATE 'T ✓6 Z/ <br /> BILLING PARTY: WNER O CONTRACTOR 0 SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)t-1 Arsenic(4393) <br /> INTENDED USE Sebomestic/Private D Irrigation/Agricultural D Industrial D Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If dlHerent from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK )(New Well ❑replacement Well ❑Well Alteration/Modification D Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) It of borings D Geotechnical a of borings <br /> ❑Out-Of-Service Well D Out-Of-Service Well Renewal D Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method I<Mud Rotary D Air Rotary ❑Auger ❑Cable Toot D Push Point ❑ Othe+r <br /> Proposed Well Depth S Q ft Excavation I In diameter ❑Open Bottom )<Gravel Pack/Gravel Size In diameter <br /> ❑Conductor Casing In diameter / Conductor Casing Depth It <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 2 Civ ❑Steel Plastic D Stainless Steel ❑Other <br /> Grout Seal Depth 200 ft D Neat Cement(94 lb bag/S10 gal wafer) ❑Sand Cement sack mix/7 gal water <br /> 'XBentonite(20%solids) D Other <br /> Grout Placement Method'KNtrped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ump Contractor ❑ Other <br /> ❑Concrete Pedestal DDlmenslons:Width ft Length ft Thick In ❑Christy Box D Stove Pipe <br /> PUMP D Submersible❑Turbine ❑Other HP Pump Set__R 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. 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 /> M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-76697 4 <br /> SIGNED 7e� TITLE DATE /—/ <br /> IfLLFT <br /> rr <br /> Lj <br /> r RCN E A <br /> T P <br /> EPrA TMEN Q OL E NLY 1r� <br /> Application Accepted By Date v Area Employee IDf--4v <br /> Grout Inspection By Dale I 1 SPECIALWell Permit <br /> Pump Inspection By� Date 0 WAIVER Received <br /> Soil g��l tion By { f Date ft <br /> Constructed Well Depth <br /> COMMENTS <br /> PE SC Received Check#/ Amount V� Permit/Cod Ifo B Cash emitted Date Service Re uest# Invoice# Well ID# <br /> 6 <br /> 2n I �U g3 <br /> v q 3 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />