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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 /> 0 NON-REFUNDABLE PERMIT l/ Qwwww.S OV.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS to OVo W•Sdi%A%+e. \kWdk CITY/LP I;-=!&t�Jf, Tom <br /> om y <br /> m <br /> CROSS STREETNgY1SCH 1Ce APN �r PARCEL IZE X03 LAND USE APPLICATION# / p <br /> PHONE ka5-�3 (o0 sa y <br /> OWNER NAME //�� � a` i 'J � A �! <br /> OWNER ADDRESS ,M COI�MIy^ &Q.Q/tlrk 1 Suxkc 7o//0,CI /S TE/LP Zry�he.m 1.1 loo�O�///_LA o" <br /> CONTRACTOR ^\�M\tIAk PHONE +46V'5 15-Sc. <br /> CONTRACTOR ADDRESS3QO 111-, CITY/STATE/ZIP ja�Jou u• ��//I� <br /> SUBCONTRACTOR/CONSULTANT V iW �•I`• PHONE�O'�`�'Tb�C��1��00 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS II CITY/STATE/ZIP C`ja,yT <br /> LICENSE XC-57 ❑C-61 D 0-09 Other NUMBER 79?"Oq EXPIRATION DATE <br /> BILLING PARTY: 0 OWNER CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private ❑IrTigation/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 ❑New Well ❑Replacement Well D Well Alteration/Modification ❑Other <br /> D Monitoring Well(s) #ofwells D Soil Boring(s) #ofborings KGeotechnical__26_0 of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal L'Cross-Connection Repair <br /> D New Pump D Pump Replacement ❑Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud a Air Rotary Auger ❑Cable Tool ❑Push Point D Other <br /> Proposed Well Dep�ft Excavation in diameter D Open Bottom Gravel Pack/Gravel Size in diameter <br /> D C nductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter IThidme§/Gauge/ASTM Schad ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Dept ,� ft eat Cement(94/b bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method Pumped 0 Free Fall ❑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 ❑Submersibleo Turbine 7 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 /> MINIMW48 HOUR ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-76697 w <br /> SIGNED �ti_(�Z�,�J TITLE , r % rc,.E <br /> �Fo <br /> 7919 <br /> R <br /> hT <br /> ARTMENT U E O L <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date / J[./,(,.��/. ❑ WAIVER Received <br /> �/ / //_�_/ <br /> Soil Boring Inspection By I Date ' -/ • Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> r-ode.p Info By Cash Remitted Date S rviceRe uest# Invoice# Well ID# <br /> X TW <br /> Al 44QN <br /> EHD 43-06 6/112019 WELL/PUMP PERMIT <br />