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L <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 n www.s ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS J Q()O • E'15 "r mo-e 9ACITY/ZIP <br /> N <br /> m <br /> �1 <br /> CROSS STREET I V 'v`t�-�e l9 ffl� APN Vag, 3�'SA qc D <br /> r PARCEL SIZE LAND USE #a <br /> OWNER NAME G<Q9h� m%ke Ry� J r�Me s�ro�(�S LLC C PHONyE(, D'\) "6"— `303 y <br /> OWNERADDRESS 3 `OO �QS� +'t8h� f `%� '`®A� CITY/STATE/ZIP " Xv 1"f\ C <br /> CONTRACTOR 'TeYYRC��n CO�1S� a,� � <br /> PHONEO I� <br /> CONTRACTOR ADDRESS Rn �n�uglr�`�` V'a�I CITY/STATE/ZIP L0&� O 0 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESSCITY/S�/�TATE/ZIP <br /> LICENSE �C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER66`irryy0A EXPIRATION DATE \ �� <br /> BILLING PARTY: ❑OWNER CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private 0 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 WORK 0 New 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 <br /> ❑ New Pump ❑ Pump Replacement 0 Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary ❑ Air Rotary Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth �O ft Excavation --in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ;�ej_ft Neat Cement(94 lb bag/5-90 gal water) 0 Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method A Pumped ❑ Free Fall Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump tn ractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimenslons:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine 0 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 CO PENSATION LAWS. <br /> MI M 48 <br /> tv <br /> CE NOTICE REQUIRED FOR INS,�P-ECTIIONSA PLEASE CALL(209)953-7697 <br /> SIGNED TITLE /f 1 f�V�FYI 1 �Vi�S�✓ DATE <br /> n <br /> ZZ <br /> o / C <br /> C T D TA EL <br /> f T <br /> � E ARTMENT U E N L Y <br /> Application Accepted By a Date Area Employee ID#� <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Z Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash RemittedDate Service Request# Invoice# Well ID# <br /> (46 *,2494a`i 10 R wpod400 3 <br /> EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />