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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY RMENTAL HEALTH DEPARTMENT 1866 EAST HAZELTON AVENUE-STOCKTON CA 95206-6232(209)460-3420 <br /> NON-REFUNDABLE ER 1T www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> JOB ADDRESS CITY21P <br /> CROSS STREET W1 I r'r &14U A� APN/ s f2��, _PARCEL SIZ& f LAND USE/APPLICATION# p <br /> OWNER NAME I _.p /�W.. ' PHONE <br /> OWNER ADDRESS d CITYISTATEID, Q( <br /> C p� <br /> CONTRACTOR -� �`�S'��..'rhind o ��,sPHONE 2_-_j 94 <br /> s2 <br /> CONTRACTOR ADDRESS /V'•�dP.rS CITY/STATE/ZJP ld I <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITYISTATE/ZIP <br /> LICENSEr��7 U C-61 if D-09 Li Other NUMBER�S��- EXPIRATION DATE90 <br /> BILLING PARTY: `\ I OWNER .CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: eneral Mineral/Coliform Bacteria(4391) ibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE1Domaslic/Privale ❑Irdgalion/Agricullurat ❑Industrial n Water Quality Monitoring 1.1 Soil Sampling/Characterization <br /> u ublic Water System <br /> II nlaoreol from Omer Wafer System Neme CWIMI Name or Phone Number <br /> TYPE OF WORK New Well 0 Replacement Well D Well Alteration/Modification D Other <br /> 17Monitorin Wells #ofweils JSoilBoring(s) Norl-Inge nnn,odnga <br /> x1 Geotechnical <br /> F1 Out-Of-Service Well D Out-Of-Service Well Renewal U Cross-Connection Repair <br /> u New Pump D Pump Replacement D Pump Repair D Raise Well Casio <br /> WELL CONSTRUCTION <br /> Drilling Method )eMud Rotary n Air Rotary D Auger D Cable Tool D Push Point f Other <br /> Proposed Well Depth."' It Excavation 1_in diameter 0 Open Bottom A(Gravel Pack/Grovel Size in diameter <br /> 1)Conductor Casing in diameter / Conductor Casing Depth 11 <br /> Well Casing Diameter-i6`-�in Thickness/Gauge/ASTM Snhed y� n fj Steel Plastic rI Stainless Steel J Other <br /> Grout Sea, Depth .¢m 0 D Neat Cement(94 Ib bag/5.10 gal water) Sand Cement IV,S sack m1xr7 gal water <br /> Bentonite(20%solids) i I Other <br /> Grout Placement Method JKPumped D Free Fall D Other D Retardant I Accelerator(name) <br /> PEDESTAL Installed By f1 Driller 'Pump Contractor 11 Other <br /> D Concrete Pedestal 0Dimensions:Width It Length it Thick in D Christy Box D Stove Pipe <br /> PUMP r]SibmersibieU Turbine a Other_ HP Pump Sel_ ft Standing Water Level it <br /> 1 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 /> MINI M 48/H.rO�UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7A697 <br /> SIGNED 7)1, /�LQ � <br /> ii. -au TITLE ©'"'Cu, DATE <br /> LA rMix 179;14" <br /> 1 <br /> P TMENT U E N L Y <br /> Application Accepted By Date Y Areal,7Employee ID#J�� <br /> Grout Inspection By Date � SPECIAL Well Permit <br /> Pump Inspection By Dale /( WAIVER Received rt� <br /> Soil Boring Inspection B Date Constructed Well Depth, to ft <br /> COMMENTSlar <br /> PE Se Received (I;hecW AmountDate Permit Invoice# Well ID# <br /> Codes fo B ash Remitted Service Re uest# <br /> a <br /> 8\ <br /> o <br /> EHD 43-05 F41112019 WELLIPUMPPERMIT <br />