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R` <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 WWW sjgov.qrg1ehd EXPIRES'I YEAR FROM DATE ISSUED <br /> o` toll 2 x'33 D `� <br /> JOB ADDRESS N o CITY/ZIP m <br /> �o`C n � _� D <br /> CROSS STREET ti'�►�n/V� 'C� AtiPN{` PARCEL SIZE AND USEQAPP-CATION <br /> # r A <br /> OWNER NAME L5 l� yt t�{l�CC(>rnnl 1\ Cow I\ --77 ff��T(' L-Le-' PHONE <br /> 1��/!^ 1,t+V� <br /> OWNER ADDRESS \ 4 3/V� `VQ l ?Pl9CfTY/STATEIZIP�V ivo— `A z <br /> LC/I-� �• Lk\ CI PHONES I <br /> G <br /> CONTRACTOR y _)- <br /> CONTRACTOR ADDRESS Z 52 Y\D�j/ ��C Cm/STATEIZIP l 0�/Krf� C / 3 <br /> SUBCONTRACTOR/CONSULTANT,"� L'�� �(/���„„���`^^,Dyy �'� t� tC, PrH•-O�NE C1 <br /> SUBCONTRACTORICONSULTANT ADDRESSg5q Nr LClM�Y` C`,,YISTATE/ZIP v 1 QL�G I�-f 1 ZC7 v <br /> LICENSE ?I C-57 F C-61 n D-09 1 Other NUMBER r ` EXPIRATION DATE <br /> BILLING PARTY: ❑OWNER ONTRACTOR 1 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(439 1)❑Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE 7 Domestic/Private ❑Irrigation/Agricultural C Industrial ❑Water Quality Monitoring Soil Sampling/Characterization <br /> 7 Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 1 New Well 1 1 Replacement Well I Well Alteration/Modification I I Other <br /> #ofbdrlfft]� <br /> -1Monitoring Well(s) #of wells f S #of borings oil Boring(s) Geotechnical y�-{ <br /> j Out-Of-Service Well L Out-Of-Service Well Renewal a Cross-Connection Repair CIC `C <br /> 7 New Pum 7 Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION �DV �i^ <br /> Drilling Method 7 Mud Rota}ry D Air Rotary Ll Auger 11 Cable Tool 7 Push Point ❑ Other Q <br /> Proposed WeIr Depth S V ft Excavation�_in diameter L Open Bottom C Gravel Pack/Gravel Size in diameter <br /> 4�-A� 7 Conductor Casing in diameter I Conductor Casing Depth n <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad C Steel C Plastic 7 Stainless Steel ❑Other <br /> Grout Seal Depth ft ? •Neat Cement(94 lb bag/5-10 gal water) C Sand Cement sack mix/7 gal water <br /> 1 Bentonite(20%solids) n Other <br /> Grout Placement Method umped 1 Free Fall Other 1 Retardant/Accelerator(name) PA 11ry' <br /> PEDESTAL Installed By 0 Driller C Pump Contractor ❑ Other �♦1 M�'•r <br /> PU7 11Concrete Pedestal❑Dimenslons:Width ft Length ft Thick in ❑Christy Box Stove Pipe VV/�/vh <br /> MP :)Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level ft ` EV <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SA 708 ?D19 <br /> ANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT IM REQUIRED LICE IS <br /> JOAQUIN COUNTY ORDIN <br /> V:ZtSURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WIT / QIj/N CO <br /> WO ERS COMPENSATION LAWS. <br /> IGNED <br /> L IU 8 E NOTICE REQUIRED INSPT11 Sr PLTAS� ALLBA09��3- 9 i q � IVTAL <br /> n' <br /> - (gip , 1 <br /> yI _ - <br /> �_____ <br /> AL <br /> Z',9 •J� TP, IF <br /> +A,-C <br /> i <br /> - - <br /> NC � PROPOSED TEST BORING LOCATION <br /> .. --�, <br /> \' <br /> PA TMENT U ET NLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL II Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Ins pectJ'�on ByG D t, n Constructed Well Depth ItaZ <br /> COMMENTS 1 -r /M YIO �le,` 7 <br /> PE Sc Received Check#I Amount Dae Permit/ Invoice# Well ID# <br /> Codes Info B emitted Service Re uest# <br /> 4 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />