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f + <br /> 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 G I /� w/w�w.s ov.or /ehd EXPIRES 'I YEAR FROM DATE ISSUED <br /> JOB ADDRESS � C.�I NI Ile- 0� CITY/ZIP < m <br /> JSA.O-* Ln <br /> D <br /> CROSS STREET ANN PARCEL SIZE LAND USE APPLICATION# p <br /> �y / A e r7 ]/' m <br /> OWNER NAME /}�/M 4�� /�L/V 7�/fG1 Jltf� PHONF�t���/(/ ren <br /> OWNER ADDRESS _ / Q oex ��Q _ _ CITYISTATE/ZIP �%�/ <br /> CONTRACTOR �� , / <br /> ��r�VL1S__ C �PHHOj /N` .a(J <br /> E ;?b "g <br /> CONTRACTOR ADDRESS Q CITYISTATE/ZIP �C�i C� n• C�/ /So�� <br /> ay 1 <br /> SUBCONTRACTOR/CONSULTANT_PaSY) PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 1 —� CIUTYISTTATTEIIZIP mod�c , y'r3s <br /> LICENSE *'---57 ❑ C-61 ❑ D-09 ❑ Other NUMBER !(y/ dL{(� EXPIRATION DATE <br /> BILLING PARTY: D OWNER D CONTRACTOR ❑ SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:�IyGeneral Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑ Arsenic(4393) <br /> INTENDED USE /141omestic/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 WORK4New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair SEp o <br /> ew Pump ❑ Pump Replacement ❑ Pump Repair D Raise Well CasingS <br /> WELL CONSTR6CTION � <br /> Drilling Method Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other QCT NM 1y <br /> Proposed Well Depthft Excavation �[� in diameter ❑ Open Botto'Vfm Gravel Pack/Gravel Size ini i T <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth / ft <br /> Well Casing Diameter 6 in Thickness/Gauge/ASTM Sched ❑ Steel Plastic ❑ Stainless Steel ❑ Other <br /> Grout Sea[ Depth ;Z"2, ft ❑ Neat Cement(94 lb bag/5-10 gal water) /-JSand Cement 21 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 ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy B,gx ❑ Stove Pipe <br /> El <br /> PUMP Submersible❑ Turbine ❑ Other HP -- Pump Set ft Standing Water Level ft— <br /> I HEREBY C TIFY 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 /> MI 8 U NOTICE REQUIRED FOR I PECTIONS -PLEASE CALL(209)�5�46/ <br /> SIGNED TITLE '// /G%'!% DATE / <br /> ARTMENT USE ONLY <br /> Application Accepted By Date Area 14 Employee ID# <br /> Grout Inspection By Date 1 PECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date onstructed Well Depth ft <br /> COMME TS19-Rib <br /> PE SC Received eck#/ Amou Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> W 1POO 4 O 135 <br /> a5" s W 4 013 7 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERI IT <br />