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* 1 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS fEXPILREjS�1 YEAR FROM DATE ISSUED <br /> �7 C� A't—P� m <br /> JOB ADDRESS��� C CITY/ZIP C m <br /> J� /^ D <br /> CROSS STREET �P� Q APIN�ti (Oc�'__4W PARCEL SIZE 2—LAND USE APPLICATION# A <br /> / m <br /> AY <br /> OWNER NAME �QIlIhO 'CL[ja�.�s Z .sr Itl[nlrl � V PHONE N <br /> En <br /> OWNER ADDRESS 73 J,4 Ate 1,4 S/, ( 041!r Or�W / CITY/STATE/ZIP L Gk 1 <br /> CONTRACTOR KQS.2 I11!r Dr Io*JW PHONNE {�U 1r1 P <br /> CONTRACTOR ADDRESS 1 /7P✓-1 J G' CITY/STATE/ZIP J�'LNneC�.Q.S�,rJ CIL <br /> zll <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE Y�C-57 ❑ C-61 11D-09 11 ('`Other NUMBER (,AY,22,� EXPIRATION DATE ZQJ_l <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑ Dibromochloropropane(4392)❑ Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ 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 ANew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings EI Geotechnical <br /> #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pum ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ?Z0 ft ( Excavation ZZ in diameter ❑ Open Bottom Gravel Pack/Gravei Size in diameter <br /> ❑ ConductorCasingin diameter / Conductor Casing Depth ft <br /> Well Casing Diameter–&— in. Thickness/Gauge/ASTM Sched�— ❑ Steel XPlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth2np�__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 yPumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Pump Contractor U Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine Cl 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'^M,,48 -HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (2099) 953-7697 <br /> SIGNED of G V�lnn�XX� TITLE / 1Pr- DATE 2-13-19' <br /> jl <br /> op) <br /> S <br /> q <br /> T C <br /> P RTMENT USE N L Y) AgRM4 <br /> Application Accepted By ate / Area Employee ID#� <br /> Grout Inspection By Date f fl ❑ ECIAL Well Permit <br /> Pump Inspection By Date F] WAIVER Received( <br /> Soil Boring Inspection By Date Constructed Well Depth S _\ ft <br /> COMMENTS <br /> / L C0442 <br /> PE SC Received eckW Amount Date Permit/ Invoice# Well ID# <br /> C es Info B Cash Remitted Service Request# <br /> *517th C1 A-1- 11 <br /> uJ P 0:)L(c) <br /> C -0 1 WiooaLl OL <br /> WELL/PUMP PERMIT <br /> EHD 43-06 8101/16 <br />