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r <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 PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> � I LAA <br /> to <br /> JOB ADDRESS CIN/ZIPto <br /> CROSS STREET APN PARCEL SIZE LAND USE APPLICATION# A <br /> ^' m <br /> OWNER NAME Yl C_1V PHONE w <br /> OWNER ADDRESS �1�I . PeY A,!I h ove CITYISTATE/ZIP 17, ��n'.' <br /> CONTRACTOR r� PHONES O )It <br /> CONTRACTOR ADDRESS 2 ��..� IAV\�... `(�6 CITY/STATE/ZIPII -� <br /> SUBCONTRACTORICONSULTANT PHON�PHHOONNE1 L7 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS LV; ,.K�--,1 'C�. CITYISTATE/ZIP \ •V) <br /> LICENSE 157 ❑C-61 ❑D-09 0❑Other NUMBER' EXPIRATION DATE <br /> BILLING PARTY: D OWNER U1 ONTRACTOR D SUBCONTRACTO CONSULTANT <br /> DOMESTIC WELL SAMPLING.❑General Mineral/Coliform Bacteria(4391)0 Dlbromochloropropane(4392 D Arsenic(4393) <br /> INTENDED USE D Domestic/Private D Irrigation/Agricultural 0 Industrial ❑Water Quality Monitoring eSoil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK D New Well 0 Replacement Well D Well Alteration/Modification ❑Other <br /> #of borings #of borings ��` <br /> D Monitoring Well(s) #of wells D Soil Borings) B'�eotechnical Y <br /> D Out-Of-Service Well 0 Out-Of-Service Well Renewal D Cross-Connection Repair �`A►� <br /> D New Pum D Pum Re lacement 7 Pum Re air C Raise Well Casin Zcie,` II�r <br /> WELL CON <br /> �STRUCTION / PA <br /> Drilling Method V Mud Rotary C Air Rotary 9'Auger D Cable Tool C Push Point C Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom [I Gravel Pack/Gravel Size in diamete J 3 0] <br /> p <br /> 1 1 Con uctor Casing 7 in diameter / Conductor Casing Depth ft SqN ��0�3 <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad C Steel 7 Plastic 11 Stainless Steel 0 Other g.s, / <br /> COU�� <br /> Grout Seal Depth ft feat Cement(94 Ib bag/5-10 gal water) -1 Sand Cement sack mix �Q^/M <br /> 0 Bentonite( %solids) C Other QEpgRT rq� <br /> Grout Placement Method Pumped C Free Fall D Other L Retardant/Accelerator(name) �Ehl J <br /> PEDESTAL Installed By 0 Driller D Pump Contractor 7 Other <br /> LJ Concrete Pedestal L]Dimensions:Width ft Length ft Thick in L Christy BOX L Stove Pipe <br /> PUMP I 1 Submersible 1 Turbine i Other HP Pump Set It 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 /> .IOAQUIN 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 /> MINIMUM H R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE r n �'r�1;'-'f1P�V DATE C <br /> U <br /> 19 <br /> E HEALTH <br /> ICES <br /> of <br /> DEPARTMENTI}UEJNLY <br /> Application Accepted <br /> Date V Area / Employee ID#�_ - <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed We 1 De th ft 4 <br /> COMMENT 1 <br /> PE Sc Received Check#/ Amount Date Permill Invoice# Well ID# <br /> Codes Info Caslhi j Remitted Z 11 Service Re uest# <br /> ��? U <br /> EHD43-06 6111/2019 2�� WELL/PUMP PERMIT <br />