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0�5 15ly <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 /> JOB ADDRESS �� ) ff V' CITY/ZIP �� �' C1� ^�� m <br /> CROSS STREET L\+�G`W_ 'JE, y{( A�(PN PARCEL SIZE 1 C r p <br /> AND USE APPLICATION# vA <br /> OWNER NAME ��HS�,r� N � `i`�� �} l PHONE <br /> , I, n y <br /> OWNER ADDRESS -I�V� vf� y � �� TI ,7� CITY/STATE/ZIP ^�/ .cft <br /> � V <br /> CONTRACTOR �-��1 LDy1 J✓t I i`s/ Pry <br /> PHONE "�y t l uVV 1 <br /> CONTRACTOR ADDRESS 1� 1��1�1 1 r``�1 W CITY/STATE/ZIP <br /> SUBCONTRACTORICONSULTANT /V/4 PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS C{ITY/STA'TEE21P 1111.4 <br /> LICENSE Q,C-57 C-61 -I D-09 I Other NUMBER '✓v —` ExPIRATION DATES <br /> BILLING PARTY: OWNER '. CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:a General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)Li Arsenic(4393) <br /> INTENDED USE Domestic/Private -1 Irrigation/Agricultural C'. Industrial ❑ Water Quality Monitoring 1-1 Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well I Replacement Well ❑ Well Alteration/Modification C' 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 C Cross-Connection Repair <br /> ❑ New Pump Pump Replacement ft Pump Repair r-I Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method K Mud Rotary Air Rotary hAuger u Cable Tool ❑ Push Point I Other <br /> Proposed Well DepthJ� I'(Lft Excavation _ in diameter ❑ Open Bottom 7 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 0 Plastic 1 Stainless Steel -] Other <br /> Grout Seal Depth ft „Neat Cement(94/b bag/5-10 gal water) r Sand Cement sack mW7 gal water <br /> El Bentonite(20%solids) -1 Other R"" <br /> Grout Placement Method Pumped CI Free Fall 1 I Other ❑ Retardant/Accelerator(name) =MMENT <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor Other �® <br /> El Pedestal❑Dimenalons:Width ft Length ft Thick in n Christy Box Stove Pipe <br /> PUMP 11 Submersible F1 Turbine ❑ Other HP Pump Set ft Standing Water LevelI 20119 <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANG WITH <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED (AOUNTY <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANC E IRUINNiE dTAL <br /> WORKERS COMPENSATION LAWS. [iEEA(-TH D`RA, ,ME-N!(- <br /> MINIMUM 48 HOUR ADVANCE NOTIC REQUIRED FOR INSPECTIONS -PLEASE CALL(209)953-7697 <br /> r <br /> SIGNED �� TITLE Llz'e' � h�,����' '�� ni DATE ��I✓�� <br /> r <br /> I <br /> DQE-rARTMENT USE ONLY t�`- <br /> Application Accepted By Date j Area -Z ' 'k employee ID# <br /> Grout Inspection By Date _ PECIAL Well Permit <br /> Pump Inspection By Date L: WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info C sh Remitted Service Request# <br /> L� ZZ _ I /.� ' <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />