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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 / IEXPPIIREEjS 1=7 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �e ��/ CITY/ZIP ��i//!/`� r/`� .111-4 <br /> , m <br /> CROSS STREET ti_e� /_/� AP <br /> /�► PARCEL SIZE LAND USE APQPrLICATION# <br /> OWNER NAMED J�/ 0 PHONE e % / U) <br /> OWNER ADDRESS _A— 7 AA -15r� y CITY/STATE/ZIP A`'– `,;r �T[ // �� <br /> CONTRACTOR _ {� �— - 7 (LF'l�iLl� PHONE / 'J <br /> V7 / ' _ �� C!t z Sze' <br /> CONTRACTOR ADDRESS 4'��Q G�/>N �C(ITY�/$TATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT /IL`s ' '�c� PHONE �- ----- – <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP___ <br /> LICENSE 0-57 ,&t-61 17 D-09 ❑ Other NUMBER J�i EXPIRATION DATE------- <br /> BILLING <br /> ATE_- --BILLING PARTY: 'OWNER ;,VCONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: eneral Mineral/Coliform Bacteria(4391) bromochloropropane(4392) Arsenic(4393)Pqy <br /> INTENDED USEDomestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Chara <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Numbe <br /> TYPE OF WORK Ll New Well Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> #of borings I c sOU <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) ❑ Geotechnical FN Qr/JJ�j(J' <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair _'q0 CNM� N11e <br /> JdNew Pum ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing HOEP4�C <br /> WELL CONSTRU TION FNr <br /> Drilling Method Wud Rotary ❑��Att�irr Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other a of <br /> Proposed Well Depth�#C— Excavation 147— in diameter ❑ Open Bottom 2ftravel Pack/Gravel Size_ 741 in diameter <br /> ❑ Conductor asing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ek ❑ Steel.0lastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth IX ft ❑ Neat Cement(94 Ib bagl5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method;)Opumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 'dPump Contractor 11 Other <br /> [I Concrete Pedestal❑Dfine_nsions:Width ft Length ft Thick in ❑ Christy Box LI Stove Pipe <br /> [PUMP Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level <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 COMPENSAION LAWS. +I <br /> MI��944XO <br /> ;;rANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209) 953-769977 <br /> SIGIE _ TITLE Aklll �G DATE Z7L <br /> Q n r <br /> f / r <br /> 6 ` <br /> 4 16 41 <br /> 61 Pp� <br /> mp <br /> V <br /> 0 <br /> _ ® Ow <br /> v — - <br /> ej <br /> 4-4 <br /> Lj -771 <br /> T1 -.1-1 1 1 <br /> f <br /> _EPARTMEN T USE ONLY <br /> r <br /> Application Accepted By Date Area oyee ID# <br /> Grout Inspection By " — Date VJPECIAL Well Permit <br /> Pump Inspection By V-r"5te (9-P(-"\ aU�� Date 2/ I& I-V 11 WAIVER Received <br /> Soil Boring In ection By Dae Constru ted Well Depth ft <br /> UM <br /> NTS �� � JAJ O Z - - <br /> PE SC Received Chec Arnounf Date Permit/ Invoice# Well ID# <br /> Codes Int ash Remitted Service Re uest# <br /> k 9-70 /s 7 WP0040Q 15 <br /> 0 <br /> 0".. <br /> 6/11/2019 WELL/PUMP PERMIT <br />