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WELUPUMP PERMIT <br /> O\� SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232209)468-3420 <br /> ( <br /> NON-REFUNDABLE PERMIT W WWW.S Ov.or /ehd / EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe A ZO V � 1dg Yt , CI1YlZIP m <br /> n D <br /> CROSS STREET APN / 1'-'C PARCEL SIZE, LAND USE APPLICATION# z <br /> ��Jr �1at <br /> OWNER NAME n '(• r ku" / r_31 i p. 's / �:. IQ1_ft :c <br /> PHONE 666 41134y <br /> OWNER ADDRESSTF1 ( (1e,L �jLL� C/'I,T,YI$TATE21Py. Y ' c_ I, 1 � <br /> CONTRACTOR W1 rl t"�1 1..!_/". '70T' I PHONE <br /> CONTRACTOR ADDRESS�y @� �(� Hcy 1�Y" !e6 CITY/STATEMIR <br /> SUBCONTRACTORICONSULTANT XU� �c(cG: PHONE D <br /> SUBCONTRACTOR/CONSULTANT ADDRESS Q!,"Owe CRY/$TATE21P J'\a4i n P.g/e'.�/g 4 <br /> LICENSE )-57 D C-61 0 D-09 0 Other NUMBER\DL1161�h EXPIRATION DATE <br /> BILLING PARTY: D OWNER CONTRACTOR D SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE 0 Domestic/Private D Irrigation/Agricultural D Industrial D Water Quality Monitoring t2rtoil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well D Replacement Well D Well Alteration/Modificafion ❑Other <br /> 0 Monitoring Well(s) #of wells D Soil Boring(s) #of borings b-Ileotechnical #of borings <br /> 0 Out-Of-Service Well D Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> D New Pump 0 Pump Replacement 3 Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION � <br /> Drilling Method D Mud Rotary C Air Rotary 7 Auger D Cable Tool t ush Point C Other <br /> Proposed Well Depth ft Excavation in diameter D Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> I I Condu or Casing in diameter / Conductor Casing Depth ft w <br /> Well Casing Diameter in Thickness`/GaugelASTM Schad D Steel 7 Plastic ❑Stainless Steel 0 Other A <br /> Grout Seal Depth ( ft tl4'Neet Cement(94 Ib bao-10 gal water) -1 Sand Cement sack mixf7 gal water ^� <br /> D Bentaniteso <br /> ids) C Other <br /> Grout Placement Methodlideumped C Free Fall Other C Retardant I Accelerator(name) A1011 o <br /> PEDESTAL Installed By D Driller D Pump Contractor 7 Other <br /> U Concrete Pedestal UDimensions:Width ft Length It Thick in L Christy Box L Stove Pipe n <br /> PUMP I I Submersible I Turbine I Other HP Pump Set ft Standing Water Level /�/OqQ(/ O�J <br /> �iR �N <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN Tye NMFCOUN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS Fpq NT,� <br /> CURRENT AND ACTIVE <br /> EILAWS.HE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WH <br /> IT <br /> WORKERS COM ALL RrM�NT <br /> MINI MM 48 HOUR NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED_ TITLE ��� �I3r r.P DATE <br /> TMENT SE ONL <br /> Application Accepted By ate V Y Area Employee ID# j;Aj <br /> Grout Inspection By Date ❑ PECIAL Well Permit <br /> Pump Inspection By Date 90 WAIVER Received <br /> Soil Boring Inspection By Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit] <br /> Codes Info Sip, Cas emitted Date Service Reguest# Invoice# Well ID# <br /> EHO 43-OB 811112019 - / / WELL(PUMP PERMIT <br />