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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 /> JOB ADDRESS Jar __ CITY/ZIP 44 _5� to <br /> m <br /> J /�J IF D <br /> CROSS STREET_ /0//-11/V/ �APN �l��C]y PARCEL SIZE Z`LAND USE APPLICATION# tj <br /> m <br /> OWNER NAME ��I PHONE ren <br /> OWNER ADDRESS �(.� CITY/STATE/ZIP <br /> CONTRACTOR PHONE qz, � <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACT /CONSULTANT ADDRESS TY/STATTTEE//ZIP <br /> LICENSE 57 U C-61 n D-09 U Other NUMBER EXPIRATION DATE'_J -- <br /> BILLING P TY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELLS ING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE estic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> FI Public Water System _ <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells 0 Soil Boring(s) #or borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service W II 11 Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump KPLImpReplacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary n Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom n 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 Depthft ❑ Neat Cement(94 lb 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 —#t <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAI" 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 953-7697 <br /> SIGNED _ TITLE DATE <br /> P <br /> Ss 1 <br /> VNr <br /> �® <br /> U <br /> ENT <br /> t <br /> w <br /> DEPARTMENT USE ONLY <br /> Application Accepted By _ Date V Area Employee ID# 9 <br /> Grout Inspection By Date I iPECILWell Permit <br /> Pump Inspection ByDate 10 /`�Lb liq_ i WAIVER Received <br /> Soil Boring Inspection Byi:4 Date Constructed Well Depth _ ft <br /> COMMENTS <br /> PE Sc Received C Amount Date Permit/ Invoice# Well ID# <br /> Codes Into B Cash Remitted Service Re uest# <br /> W 00 4 oa 14 <br /> EHD 43.06 6/1112019 <br /> WELL(PUMP PERMIT <br />