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t <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 <br /> I (PERMIT www.sjqov.org/ehd EXPIRES 1 YEAR FROMDATEISSUED <br /> JOB ADDRESS �r711"17CITY/ZIP I\t IfJ 0 V) G lei l�" m <br /> � ,�, �ry ��1 ILD <br /> CROSS STREET GcJ I J� p,11� APN ^I a/v PARCEL SIZE �LAND USE APPLICATION# o <br /> / / ,{► � (� (� m <br /> OWNER NAME" N - �GCLL 'uU^ CA <br /> 1 ! PHONE (�J(:'61 a �� <br /> (; �,,v ,�yam' <br /> OWNER ADDRESS 1 _ /y r /` �` O 0"AX Z�C/STATE/ZIP J t f <br /> CONTRACTOR QJ�/1 ly►^[`[/ti 4 PHONE>frc,2-- 1' _2k <br /> 9 <br /> CONTRACTOR ADDRESS 19 <br /> / �f � CITY/STATE/ZIP M-1d 2 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 i_. C-61 D D-09 Other NUMBER &0 T6Z Z EXPIRATION DATE�®Z/ <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 11 Soil Sampling/Characterization <br /> F Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well X Apr <br /> Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells Li Soil Boring(s) #of borings I- Geotechnical Ylike —#W <br /> '1,c <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> I New Pump ❑ Pump Replacement ❑ Pump Repair -1 Raise Well Basing <br /> WELL CONSTRUCTION SAN✓ 19 <br /> Drilling Method KMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other E ng_ / <br /> Proposed Well Depth.30,0ft Excavation 12, in diameter i� Open Bottom Gravel Pack/Gravel Size TNr <br /> ;j Conductor Casing in diameter / Conductor Casing Depth ft TW yr <br /> Well Casing Diameter In Thickness/Gauge/ASTM Sched ❑ Steel XPlastic Stainless Steel Other <br /> Grout Seal Depth ft = Neat Cement(94 Ib bag/5-10 gal water) Lj Sand Cement sack mix/7 gal water <br /> pl,Bentonite(20%solids) ❑ Other <br /> Grout Placement Method - umped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller "pump Contractor a Other <br /> Concrete Pedestal❑Dime sions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP 1-1 SubmersibleC 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 /> CURR"T 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 /> ' ) p <br /> SIGNED L TITLE bt-tapy- DATE tJ`Z Z`I 7 <br /> c <br /> INV <br /> DEP TMENT USE ONLY I <br /> Application Accepted By F7 Date �J Area � 14 C Employee ID#�Ojv <br /> Grout Inspection By Date r SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER ReCeived <br /> Soil Boring Insp�ction By Date Constructed Well Depth ft <br /> COMMENTS b�0 � 'i <br /> 1A 41&16" q_LAj_" I t1k V,4 Q �l�- (OQ*d 26 <br /> PE Sc Received Ch Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> zo,00 V30 OPS D6iqCi <br /> q391 'I ( .D"0 S 2 ----I it --- <br /> 70.ov ----. <br /> r' <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />