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1 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NUN-KEFUNDABLEE 7 FERMIIT R _ www.S Ov.or /end tXFIKtb 1 YEAR FROM UATE ISSUED <br />JOB ADDRESS 4'S 1JOAQiAIAO_ _ req . CITY/ZIPS+04L't+)f . lc,_ _QV1 <br />%j fto <br />CROSS STREET Ir �QQ_ APPa Q {�9__ LZO _61 � PARCEL SIZE• $ LAND USE APPL7ICATION�#_ <br />OWNER NAME �1.Cy►grd t� Ayt c ^^Q l Cowej Y__ PHONE _ ttq 31-065S C <br />OWNER ADDRESS+ B.�AN O 1`N CITY/STATE/ZIP S��Tar l C4 ?5.215s* <br />CONTRACTOR •Ctits LL�,1K*C�y�hi • PHONE SZZ I Isis <br />t y <br />CONTRACTOR ADDRESS l \A A] rb JK, q . _ CITY/STATE/ZIP ������ CA (S i J J <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE )6-57 Ll C-61 ❑ D-09 a Other <br />BILLING PARTY: I I OWNER <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER wo%az EXPIRATION DATE q26 "Z I <br />SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring r. Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Ovvner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings F1Geotechnical _ # of borings <br />13 Out -Of -Service Well 171 Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary ❑ Air Rotary 0 Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth %0 1 ft Excavation _ [_ in diameter 0 Open Bottom Gravel Pack/Gravel Size__ in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameters__ in Thickness/Gauge/ASTM Sched '2&0 ❑ Steel Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth /6 a ft U Neat Cement (94 lb bag/5-10 gal wafer) ❑ Sand Cement sack mix17 gal water <br />'(Bentonite (20% solids) ❑ Other <br />Grout Placement Methodxumped C Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ump Contractor ❑ Other <br />0 Concrete Pedestal []Dimensions: Width ft Length ft Thick in ❑ Christy Box U Stove Pipe <br />PUMP ❑ Submersible LI Turbine a 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 />48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209))953-7697 <br />SIGNED -TITLE O GfJh'« • DA1'L" 9-27-0 <br />PARTMENT USE ON Y <br />Application Accepted By Date <br />Grout Inspection By _ _ Date 9 <br />Pump Inspection By _ Date <br />Soil Boring I <br />COMMENTS <br />Date <br />Areamployee ID# <br />YIISPECIALLWellrermit <br />WAIVER Received <br />Well <br />ft <br />v <br />0 <br />m <br />m <br />U) <br />M�. <br />Service Request # <br />e <br />WAR <br />r*h11jWW#= <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />