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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 wwvy.sjgov.org1qhd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS ' {/) / .I V/ l / - Cm/LP <br /> in <br /> CROSS STREET�'l.1/►��,.yj {�J� (/ n APNN� �p -17Qr ARCEL SIZELAND USE APPLICATION <br /> 9 <br /> OWNER NAME /r l r age I (�T�f 7 l C JPHONE <br /> OWNER ADDRESS 61 (///. i��7't �.�:� - 9' 11•?/�!� CmISTATEMP //"'I <br /> CONTRACTOR '. 2 PHONE <br /> ' / �j ~�'• <br /> -� <br /> /p� / <br /> CONTRACTOR ADDRESS �� � ly/I//JJ- V�r�"� /'�)';- CITYISTATE/ZIP '-��'11;-J yC <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT AQDREss 11CITYISTATE21P <br /> LICENSE ._C-57 `_d -61 7 D-09 --Om <br /> Other Z NUtER i� Zy 75� EXPIRATIONDATE_ <br /> BILLING PARTY: _OWNER 1140NTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)E:Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE 9115ornesticiPrivate C Imgation/Agricullural =Industrial _Water Quality Monitoring - Soil Sampling/Characterizalion <br /> Public Water System <br /> If dillemnt from O.m°r. Wale,SrMem Name Conlact Nam or Phone Ni,mtw.r <br /> TYPE OF WORK = New Well -_ Replacement Well ,Well Alteration/Modification Other <br /> =Monitoring Well(s) #of wells -SoilBoring(s) #OrhO""sz Geotechnical ltorbodngs <br /> Out-Of-Service Well Out-Of-Service Well Renewal Crass-Connection Repair <br /> New Pump Pump Replacement =Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTON <br /> Drilling Method ❑Mud Rotary Air Rotary Auger Cable Tool _:Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom 7 Gravel Pack/Gravel Size in diameter ,rte <br /> Conductor Casing in diameter / Conductor Casing Depth It P <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic _]Stainless Steel -Other g <br /> tv����� <br /> Grout Seal Depth ft LiNeat Cement(94 lb bag/5-f0 gal wafer) -1 Sand Cement sack mixl7 gal water #�I <br /> Bentonite(20%solids) Other , <br /> Grout Placement Method C Pumped 5 Free Fall ❑Other C Retardant/Accelerator(name) SB <br /> EWSAI& Instilled By -Driller G.PGmp Contractor,_ _ Other `� <br /> Concrete Pedestal Dimensions:Width R Length ft Thick " in Christy Box -Stove Pipe (®,(�' <br /> PUMP ulxnersible�Turbine C Other HP Pump Sel /€' _R Standing Water Level ft ���R����(,' V <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN 4TND V:'00,V <br /> ORDINANCES,JOAQUIN COUNTY STATE <br /> CURRENT AND ACTIVEVE WITH THECALIFORNIA CONTRACTORS STATE L CENSE BOARDS T AND THAT AI MIN CLICENSEREQUIRED <br /> COMPLIANCE WITH ALL �R�MFiyT <br /> WORKERS C MPENSATION S. <br /> ADVANCE NOTICE REQUIRED FOR INSPE�TiOI,\S - 'LE• SE GALL(20:;)�py�(53-T�y�T <br /> SIGNED TITLE 0i -, / e L DATE_rJ_ f1 ~• <br /> = l � <br /> 1 --1 f <br /> % �\ <br /> I T <br /> =le <br /> NT U N L Y <br /> Application Accepted By Areae Employee ID# 'V <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By 'S i G' r Date I:.i -�I ( = WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permil/ <br /> C Into B Cash Rernifted Da Service Request# Invoice# Well ID# <br /> c` wPo Owl <br /> EHC43-06 &IV2019 <br /> WELL/PUMP PERMIT <br />