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WELLIPUMP PERMIT LOB, <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDA13LEE�P/E�RJMIT WWW.Sjgov.org/ehd EXPIRES 1 YEAR FROM DATES ISSUED <br /> JOB ADDRESS /(�G //C/` CITY/ZIP7 I� <br /> " D <br /> CROSS STREET !/!/D �'f� APN ��17 ^Z`t'V �'��/ PARCEL SIZE •OS LAND USE APPLICATION# p <br /> OWNER NAME �r/�'�/'� f � P H 0 N <br /> OWNER ADDRESS ` CITYISTATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS Z D ,Lc��c / CITYISTATE/ZIP_ <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS,lac AACI//T,,Y,,/SSTATE/Z/IP� <br /> LICENSE VC-57 -61 ❑ D-09 ❑ Other NUMBER 4(0 © <br /> a o 1 (0 EXPIRATION DATE <br /> BILLING PARTY: ❑OWNER ❑CONTRACTOR 0 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE 0 Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> 0 Public Water System peva <br /> If different from Owner: Water System Name Contact Name or Phone Number T <br /> TYPE OF WORK 0 New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other D <br /> ggr�g- <br /> 0 Monitoring Weil(s) #of wells ❑ Soil Boring #of borings #of b <br /> s) ❑ Geotechnical J�I7 �O <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal 0 Cross-Connection Repair 21, <br /> i <br /> 0 New Pum um Replacement ❑ Pum Repair 0 Raise Well Casing9 SAN J <br /> WELL CONSTRUCTION HIRONMEN NTy <br /> Drilling Method 0 Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point 0 Other DEpAar <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter NT <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel 0 Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) 0 Sand Cement sack m/x/7 gal water <br /> 0 Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped 0 Free Fall 0 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 /> PUMP ubmersible❑ 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COM ENSATION LAWS. <br /> MINMU NCE ��EQUIREID FOR INSPECTIONS -PLEASE CALL(209)953- 697 <br /> SIGNED _?) TITLE f Y�K� �� DATE G <br /> Vol <br /> i <br /> EPARTMENT USE <br /> ONLY <br /> Application Accepted By s Date V Area Employee ID# �1 A <br /> Grout Inspection By j Date ❑ PECIAL Well Permit <br /> Pump Inspection By Yn Date 10 to�iloi ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> C lad q& Info ash Remitted Service Request# <br /> S o 40 8 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />