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SCMNED "j <br /> �C <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 /> LA <br /> JOB ADDRESS `d'4 ZX Of/(J�� /�]_LJ CITY/ZIP m <br /> CROSS STREET v/- l _APN �/ O O ARCEL SIZE 1-r-TAND USE APPLICATION#_ 0 <br /> OWNER NAME ��L �J Jlv -_v{,/ /_ _ - _ -- — PHONE- w/�O / — !7�7— 3 ui <br /> OWNER ADDRIESS O(/ �/�'`yJ�F � �Y CITYISTATE/ZIP4k <br /> �ALD !/ll <br /> CONTRACTOR !/ /'�-/// ` S' - cPHONE <br /> CONTRACTOR ADDRESS ��f�('}C // _ CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT r- PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CIT�YISTATEIZIP <br /> r9a- Er <br /> LICENSE 57 /0-61 0 D-09 ❑ Other NUMBER !`� EXPIRATION DATE <br /> BILLING PART/Y: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:i General Mineral/Coliform Bacteria(4391)I Dibromochloropropane(4392) -Arsenic(4393) <br /> INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System _ <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK n New Well D Replacement Well 17 Well Alteration/Modification CI Other <br /> ❑ Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal U Cross-Connection Repair <br /> 0 New Pump Aump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary ❑ Air Rotary 0 Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom n 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 LI Plastic ❑ Stainless Steel 0 Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) LI Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) 0 Other <br /> Grout Placement Method ri Pumped 0 Free Fall 0 Other IJ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 0 Pump Contractor 0 Other <br /> ❑ Concrete Pedestal❑Dimensions:Width fl Length ft Thick in ❑ Christy Box LI Stove Pipe <br /> EuMP NSubmersible❑ Turbine LI Other HP :�_ Pump Set ft 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 /> 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 /> ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209) 9�7 <br /> SIGNED L/ �� _ TITLE ��EC� - DATE <br /> PARTM ENT USE// NLY <br /> -Application Accepted By Date r v Area Employee ID# � <br /> Grout Inspection By _ Date I <br /> ^_ I PECIAL Well Permit <br /> Pump Inspection By 1, f-` Date N 1''1 _ i WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth� — ft <br /> COMMENTS _ 4 <br /> PE SC Received Amount Date Permit/ Inv IIID# <br /> Codes Info Cash Remitted Service Request# <br /> F qQ <br /> Ty N U <br /> 44 <br /> EHD43-OC+ 6/11/2019 xi LL/PUMP PERMIT <br />