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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 www.s' Ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JoeA DRE S 22 aA) CITY//zIPP f*O C 44 D <br /> CROSS STREET ( APN Cih1�, PARCEL SIZE L_"lq-pLAND USE APPLICATION# <br /> 1n/ -_ m <br /> OWNERNAME / fn�'0001 /�,r �.,,..I�..L'� 1 Ql_a La PHONE—�_.r_,_ >=►L, 7�1� y+ <br /> J <br /> OWNER ADDRESS 7>y/o � Gt CITY/STATE/ZIP,S�, r :.._ 11 <br /> �. <br /> CONTRACTOR �t Aln�n),I_..` !` PHONE,/').dQ1: <br /> CONTRACTOR ADDRESS gip,.� `{(1, .ki?OA _ oG CITY/STATE21P <br /> SUBCONTRACTOR/CONSULTANT Y �� ���'A PHONE <br /> SUBCONTRACTOR/CONSULTANTADDRESS t p fl�� � CITY/ST1ATE/ZIP I(AOIJ''j 11l9,Z <br /> LICENSE V47 D C-61 D D-09 0 Other NUMBER Ll EXPIRATION DATE <br /> BILLING PARTY: D OWNER \Z'—CONTRACTOR ❑ SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE D Domestic/Private D Irrigation/Agricultural D Industrial D Water Quality Monitoring IlTtooll 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 D Replacement Well ❑Well Alteration/Modification D Other q'► <br /> D Monitoring Wells #of wells ❑Soil Bode s #of boringsIR-<eotechnical #of borings <br /> D Out-Of-Service Well ❑Out-Of-Service Well Renewal D Cross-Connection Repair <br /> D New Pump 0 Pump Replacement 7 Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION � gyp' <br /> Drilling Method D Mud Rotary C Air Rotary 7 Auger D Cable Tool ""Kush Point C Other 4,4 ® <br /> Proposed Well Depth ft Excavation in diameter 7 Open Bottom ❑Gravel Pack/Gravel Size in`pla U <br /> I I Condu o g in diameter / Conductor Casing Depth ft P' V1R 1N CQt/ <br /> Well Casing Diameter_�n Thickness/Gauge/ASTM Schad 7 Steel 7 Plastic D Stainless Steel ❑Other <br /> Grout Seal Depth6,ft 4 least Cement(94 Ib bag75-10 gal water) -1 Sand Cement sack mix/7 gal water <br /> D Bentonite(20%solids) C Other <br /> Grout Placement MethodII04fumped C Free Fall 2LOther C Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller ❑Pump Contractor 7 Other <br /> U Concrete Pedestal UDimensions:Width It Length ft Thick in L Christy BOX L Stove Pipe <br /> PUMP I i Submersible I Turbine I 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 /> MINI M�ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED_ TITLE �k gI6�l�d.K' DATE <br /> LL L <br /> P RTMENT U E N L Y <br /> Application Accepted By ate Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date I ❑ WAIVER Received <br /> Soil Boring Inspection By-k-Wil Date h 121 171 Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cas RemittedService,R e t# <br /> Vill <br /> EHD43-06 6/11/2019 16102,3 ` ! WELL/PUMP PERMIT <br />