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J <br /> WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95206-6232(7.09)468-3420 <br /> NON-REFUNDABLE PERMIT L www.siaov.org/ehd Cod I YEAR FROM DATE ISSUED <br /> JOB ADDRESS ` I 1 O 3 N . �QC k+onG Q CIN/ZIP (i�4 f{ l,Jl 952y0 m <br /> /� <br /> C q�ry� D <br /> CROSS STREET VP-C Ott k APN b 3 2. I c1 PARCEL SIZE 5241PAND USE APPLICATION# o <br /> v-�kl E4'd 4C� -C fI1NIt11L ( SI s <br /> OWNER NAME l i� F ePHONE_] 2-^ J m <br /> OWNER ADDRESS � 1 C L��I C Izcl CITY/STATE/ZIP J O CSF'O 1,5115 <br /> CONTRACTOR ["QS{I i r D r 1l`V,r Kc. PHONE <br /> CONTRACTOR ADDRESS I 1 A lben� leek CITYISTATE/ZIP O j'�J/ <br /> SUBCONTRACTORICONSULI ANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP Q I '7 <br /> LICENSE Xj C-57 D C-6'1 0 D-09 L1�Other NUMBER��z_ ExPIRATION DATE-31-7-1 <br /> 1-7— <br /> / <br /> BILLING PARTY: IOWNER 1/CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:'i General Mineral/Coliform Bacteria(4391)1 1 Dibromochloropropane(4392), Arsenic(4393) <br /> INTENDED USE D Domestic/Private L rrigalion/AgliCLlllural D Industrial 11 Walei Quality Monitoring LI Soil Sampling/Characterization <br /> 0 Public Water System <br /> If niffereut Iron Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK F eW Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> 0 Monitoring Weil(s) #of Wells U Soil Boring(s) #or borings 0 Geotechnical— #or borings <br /> 11 Out-Of-Service Well 11 Out-Of-Service Well Renewal LI Cross-Connection Repair <br /> n New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing _ <br /> WELL CONSTRUCTION <br /> Drilling Method)(Mud Rotary n Air Rotary 0 Auger 0 jpble Tool D Push Point (I Other <br /> Proposed Well Depth 5640 R Excavation 7.0 in diameter 11 Open Bottom XGravel Pack/Gravel Size in diameter <br /> U Conductor Casing in diameter / Conductor Casing Depth 9 <br /> Well Casing Diameter IL. Thickness/Gauge/ASTM Sched Z 00 U Steel )6astic n Stainless Steel 0 Other <br /> Grout Seal Depth 2D�J It D Neal Cement(94 Ib bag/5-10 gal water) D Sand Cement sack mix17 gal water <br /> 21'Bentonile(20%solids) 0 Other <br /> Grout Placement Method JXPumped ❑Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor O Other <br /> D Concrete Pedestal UDlmensions:Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP 0 Submersible Ll Turbine U Other HP__ Pump Set If Standing Water Level fl <br /> I FIEREBY 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 /> MIN HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)963-7697 w <br /> SIGNED TITLE "K DATE <br /> 1 a <br /> D <br /> 1 — - - O <br /> 1 \1 � <br /> N 01 <br /> _ N <br /> PA TMENT�LUS�n , E pNLY <br /> Application Accepted By le '<'< , ` Area Employee ID# � <br /> Grout Inspection By_ Dale ._ 1! PECIAL Well Permit <br /> Pump Inspection By Dale_ WAIVER Received <br /> Soil Boring Inspection By — Date Constructed Well Depth h <br /> COMMENTS <br /> PE Sc Receivedheck#I Amount Date Permit/ Involve# Well ID# <br /> 'ode Info B Remitted +�1 �1 +I Service Re uest# <br /> EHD41-06 6/11/2019 WELL/PUMP PERMIT <br />