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19525 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> ti <br /> JOB ADDRESS 1636 EI Camino Ave CITYIZIP Stockton,CA 95209 <br /> m <br /> D <br /> CROSS STREET Capistrano Ave APN 075-140-550 PARCEL SIZE I ac LAND USE APPLICATION# v <br /> A <br /> OWNER NAME Paula Williams PHONE (916)782-8700 y <br /> OWNER ADDRESS 1636 EI Camino Ave CITYISTATE/ZIP Stockton,CA 95209 <br /> CONTRACTOR Eaton Pumps Sales&Service PHONE 530-661-6737 <br /> CONTRACTOR ADDRESS 10 W Kentucky Ave CITY/STATE/ZIP Woodland,CA 95695 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 0 C-57 C-61 D-09 Othef NUMBER 133783 EXPIRATION DATE 07/31/2020 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ■Domestic/Private D Irrigation/Agricultural Industrial 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 E3 New Well Replacement Well Well Alteration/Modification ■Other Pull Pump for Well Video Survey <br /> # <br /> Ll Monitoring Wells) #of wells Soil Boring #of bonngs s) Geotechnical of borings PA <br /> ❑Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> D New Pum I7 Pump Replacement ■Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rotary ❑Air Rotary Auger Cable Tool Push Point D Other <br /> Proposed Well Depth ft Excavation in diameter D Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft e3AN <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel CI Plastic i Stainless Steel OtherAq��N <br /> Grout Seal Depth It Neat Cement(94/b bag/5-10 gat water) LI Sand Cement sack mixr7 l� RONM COON' <br /> Bentonite(20%solids) Other DFp FNTq� <br /> Grout Placement Method Pumped Free Fall Other i Retardant/Accelerator(name) �RTMENT <br /> PEDESTAL Installed By Driller D Pump Contractor Other <br /> D Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVAWE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Authorized Agent DATE 08/16/2019 <br /> PA TMENT SE NLY r <br /> Application Accepted By Date Area Employee ID#j4+y,�p'�Cn� <br /> Grout Inspection By Date PECIAL Well Permit <br /> Pump Inspection By DateL` 1 1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS 4 'o - I LLj <br /> � <br /> PE SC Received ec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info sh emitted .I S 'ce Re <br /> 1� !. <br /> EHD 43-06 revised 4/14/18 WELL(PUMP PERMIT <br />