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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.S Ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 167 09 'xa 17— Q <br /> • CITY/Zip H +b/, m <br /> CROSS STREET Mwr towf APN 2,03-226 PARCEL SIZE 7•y LAND USE APPLICATION# p <br /> T Cch <br /> OWNER NAME 1 �'tre.$�____Azev-ed Q j� n PHONE �2—-U-L(49 <br /> OWNER ADDRESS V4:ID_o_q- I slw, CITY/STATE/ZIP _r Ce, 4s3"� <br /> CONTRACTOR Masc llij PHONE <br /> CONTRACTOR ADDRESS meq, R 1 be r CITY/STATE/ZIPMad'e-1116 , C 'l <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP _ <br /> LICENSE XC-57 ❑ C-61 ❑ D-09 i_l Other NUMBER 41&a2,-. EXPIRATION DATE_ ' I•Z� <br /> BILLING PARTY: I I OWNER (CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private n 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 JCNew well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> P Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New PLIMP ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method�l Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth _ft Excavation _12 in diameter ❑ Open Bottom q Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Lasing Diameter-G— in Thickness/Gauge/ASTM Sched '700 ❑ Steel XPlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth__Io P_fl ❑ Neat Cement(94 lb bag/5-10 gal wafer) ❑ Sand Cement sack mix/7 gal water <br /> ))Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> rPUMP ❑ 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNI-D TITLE 0��>ti!e, DATE i x-2,7-14 <br /> If <br /> fie_ <br /> 4.0 <br /> A <br /> t --SEp- <br /> tv, <br /> _ <br /> e Ul 4 C 1J T Ir <br /> . .c <br /> ,.ISti10iZ. ARTMENT U E ONLY <br /> Application Accepted By n Date Area Employee ID# <br /> Grout Inspection By Date 0 SPEC AL Wel) Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth __ ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount ate Permit/ Invoice# Well ID# <br /> Cods Info Cash Remitted Service Request# <br /> 0 i 3 <br /> d v G <br /> EHD 43-06 6/1112019 WELL/PUMP PERMIT <br />