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` WELL/PUMP PERMIT leg SWNED <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 /> �['' n_ cod Ga 1752c/D <br /> JOB ADDRESS _N. . �) ACo ne' R CIN/ZIP_� m <br /> CROSS STREETILY"e _b¢_L_ /�APN SZZSQ IIZ 1 � ' PARCEL SIZE AND USE APPLICATION <br /> ¢l1C L # <br /> OWNER NAME �leC�h � +ol� // �QCGrVY�{ F < PHONE-12 <br /> !!! 7 (Al <br /> PHONE <br /> -- j---- - <br /> OWNER ADDRESS 9�L49 C k- `6 I^ �y`��_ __ CITY/STATE/ZIP S+6 G� � <br /> CONTRACTOR rAas{(lir D 1-x11 din ,Y • _ _ PHONE 5-2211q?, <br /> CONTRACTOR ADDRESS A I pee-S �� __ CITY/STATE/ZIP 1MD j_-*S�d/ r4l 1"5351 <br /> 1 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS _ CITY/STATE/ZIP _ <br /> LICENSE XC-57 I 1 C-61 ❑ D-09 L1 Other NUMBER_&109(02Z.__�__ EXPIRATION DATE(�f-#31-2-1 -- <br /> BILLING PARTY: OWNER '/,ONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:i I General Mineral/Coliform Bacteria(4391)I I Dibromochloropropane(4392)! Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private rrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring F1 Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK XewWeIl ❑ Replacement Well ❑ 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 CI Cross-Connection Repair <br /> n New Pump D Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)(Mud Rotary ❑ Air Rotary ❑Auger ❑ C-able Tool ❑ Push Point it Other <br /> Proposed Well Depth_SGd ft Excavation A-_ in diameter U Open Bottom 19Gravel Pack/Gravel Size 10 in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter I jp Thickness/Gauge/ASTM Sched Z Od El Steel Plastic P Stainless Steel ❑ Other <br /> Grout Seal Depth '26�J ft ❑ 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 Xpumped ❑ Free Fall ❑ Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box Ll Stove Pipe <br /> rPuMP Fj 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 /> MIN 18 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Ietr/ DATE 6 <br /> 1 Q a <br /> 0 <br /> �I 1 <br /> -17 <br /> !v � <br /> I � <br /> H <br /> _ PA, <br /> I <br /> IIIT- <br /> PA TMENT USE [ NLY <br /> Application Accepted By to 1 1 Area Employee ID# <br /> Grout Inspection By Date 11/ /1�) PECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTSOff <br /> _ <br /> PE Sc Received heck#1 Amount Permit/ <br /> Coder, Info B Remitted Date Service Re uest# Invoice# Well ID# <br /> LJ <br /> EHD 43-06 6111/2019 WELL/PUMP PERMIT <br />