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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 www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> LA <br /> Q \ <br /> JOB ADDRESS 6CK `1;,/�Uf f�T CITY/ZIP SiX30 u'\ cod 7-o3 m <br /> 1 /J D <br /> CROSS STREET Ncvab UX Anc oI1) /r./Q APN �.J�DZ4 -65 PARCEL SIZE v� AND USE APPLICATION# z <br /> M <br /> OWNER NAME PHONE <br /> OWNER ADDRESS �r� ( / CITY/STATE/ZIP <br /> CONTRACTOR /`);t ` C�. Anc�u S�>. Tt J/GSW PHONE `7cldl 3l�'!' 310 <br /> CONTRACTOR ADDRESS `(b2 ����;{� 1 VQc CITYISTATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT —^� Q_ PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP C�'. <br /> LICENSE x C-57 _ C-61 _ D-09 - Other NUMBER LiL<<CO�I EXPIRATION DATE ZOZ <br /> BILLING PARTY: _OWNER )CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391)LDibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private L Irrigation/Agricultural _' Industrial L Water Quality Monitoring D 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 _.I Replacement Well L 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-Conn ction Repair <br /> New Pump i Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodMud Rotary Air Rotary x Auger - Cable Tool Push Point Other <br /> Proposed Well Depth 2c` ft Excavation ( in diameter Open Bottom - 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 ft 'Y Neat 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 - 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 _ Submersible_ 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 COMPENSATION LAWS. <br /> MINIMUM 40 HOUP ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE DATE I O 'L "moi°t <br /> czz <br /> 2e c J <br /> O <br /> H O N <br /> M <br /> EP RTMENT U E 9NLY <br /> Application Accepted By Date l Area Employee ID#� <br /> Grout Inspection By Date F SPECIAL Well Permit <br /> Pump Inspection By Date I WAIVER Received <br /> Soil Boring Inspection By AM 4611164 Date �rTq Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received heck#/ Amount Permit/ <br /> odes Info B a emitted Date Service Request# Invoice# Well ID# <br /> 2 as 0 t - 0 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />