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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 / �/f� www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP� ��� m <br /> CROSS STREET wVO C � 6-rvev _APIN / �/ d "�+PARCEL SIZE ZrLAND USE APPLICATION# o <br /> OWNER NAME " ���� '%% 771 PHyf?`,��tJ <br /> OWNER ADDRESS oje Z/' CITY/STATE/ZIP <br /> CONTRACTOR _ /" `DISI /`,%� S /'��v/S PHONE �g,,�/I <br /> CONTRACTOR ADDRESS` <Zd ��LGf,7 C /�� CITY/STATE/ZIP -5rte/ ,5*4 fe' Z <br /> SUBCONTRACTOR/CONSULTANT �� PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP _ <br /> LICENSE F1 C-57 ❑ C-61 I1 D-09 u Other NUMBER 'W ` EXPIRATION DATE_ C <br /> BILLING PARTY: OWNER I CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) !-1 Dibromochloropropane(4392) .' Arsenic(4393) <br /> INTENDED USE omestic/Private 11Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> G Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> 17 Monitoring Well(s) #of wells 11 Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump JUPumpReplacement ❑ PUrnp Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary 11 Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth^ ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) _ <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other _ <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in U Christy Box ❑ Stove Pipe <br /> I UMP submersible❑ Turbine ❑ Other _ HP _ Pump Set ft Standing Water Level <br /> I HEREBY C TIFY THAT 1 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 /> 8 U10 ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209)`9!53/6 7 <br /> SIGNED _ _ _ L TITLE_... <br /> 1 <br /> EPARTMENT USE ONLY <br /> Application Accepted By Date Area—,4/ Employee ID# � <br /> Grout Inspection By A Date 1 1 SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth _ ft <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit/ Invoice# <br /> IV <br /> Codes Info Cash Remitted Service Request# <br /> S 'Qo -� <br /> SAN /R NICO <br /> 1DU 1, <br /> EHD 43-06 6/11/2019 WELL4 INZ PERMIT <br />