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r • <br /> ar+� <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1666 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS if L - CITY/ZIP 'z-5 J 7 I <br /> �/ D <br /> CROSS STREET ^fC..455a62 /I / APN ���{�I V O PARCEL SIZE LAND USE APPLICATION <br /> /# <br /> /J�/ 4Y , <br /> OWNER NAME ��'1 I I �l�C-r�( PHONE � 2 <br /> OWNER ADDRESS L CITY/STATE/ZIP :7 C/ C7/�7Z <br /> CONTRACTOR lye �_. C U J'✓)A PHONE �2C —Z-7Y' <br /> CONTRACTOR ADDRESS = fY)(k4fri CITY/STATE/ZIP I/I iia <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATE/ZIP <br /> LICENSE /�C-57 D C-61 17 D-09 U Other NUMBER �' ExPIRATION DATE <br /> BILLING PARTY: ❑OWNER U CONTRACTOR it SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)'j Dibromochloropropane(4392)11 Arsenic(4393) <br /> 0 Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> ri� <br /> If different from Owner: Water System Name Contact Name or Phone Number tjA <br /> TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> K of botlngs <br /> ❑Monitoring Well(s) #of wells 0 Soil Boring(S) ❑Geotechnical �� C <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal ❑Cross-Connection Repair J/iA' C� <br /> 0 New Pump PKPumpReplacement 0 Pump Repair 0 Raise Well CasingV'IJA <br /> WELL CONSTRUCTION ZM <br /> Drilling Method ❑Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point D Other O /- <br /> Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel ieter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft ENT <br /> Well Casing Diameter_in ThicknesslGauge/ASTM Sched ❑Steel 0 Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth fl 0 Neat Cement(94 Ib bag15-10 gal water) 0 Sand Cement sack mixl7 gal water <br /> 0 Bentonite(20%solids) ❑Other <br /> Grout Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor ❑ Other <br /> G Concrete Pedestal DDlmenslons:Width_ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP 0 Submersible0 Turbine D Other HP�_ Pump Setft Standing Water Level _R <br /> 1 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 WS. <br /> MINIMU R ADVANCE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE�l/y <br /> v / <br /> a Of. 1 1 NI <br /> Y C <br /> r <br /> r <br /> E A M E N T Ott 5dE(,��-0 L Y <br /> Application Accepted By Date 1 Area r Employee ID# `r�'r dam,/� t <br /> Grout Inspection By <br /> / ZX Date 7, SPECIAL Well Permit <br /> Pump Inspection By Date .. WAIVER Received <br /> Soil Baring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> odes Info B ash Remitted Service R uest# <br /> I <br /> EHO43-06 6/112019 � / 7 7 / r WELL[PUMP PERMIT <br />