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i <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)4683420 <br /> NON-REFUNDABLE PERMIT .sjgov.orglehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS \ lYy �/ i L& ( , I ` 1` \ CfrY21P I m <br /> CROSS STREET �1/l L� APN PARCEL SQE��LI�i ��t -�a�� � '�__ <br /> LAND USE APPLICATION# A <br /> OWNER NAME 1ir,_1� /�� ,Ci1�� PHOONE <br /> OWNER ADDRESS /nn=/[J O l/V C/I / J CI Y/STATE2IP b'V I ` ✓ '' ` ���I <br /> CONTRACTOR ,'C.� 11��`L"L�~ JLPHONE /��~�,}-� <br /> CONTRACTOR ADDRESS C}I V `�� l J CITY/STATE2IP L.,)J � l I /�/� , <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CrrY/STATE2IP <br /> LICENSE iec-57 ❑ C-61 D-09 ElOther NUMBER LI if oI�'l' I EXPIRATION DATE I l l <br /> BILLING PARTY: ❑OWNER D CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:�i General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private ' Irrigation/Agricultural - Industrial n 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 J New Well Replacement Well i i Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells K-4o4 B'orin�s)L ` #"b-D95 Geotechnical #of borings <br /> ❑ Out-Of-Service Well i Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement 1 Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary F Air Rotary 'A"Auger -1 Cable Tool I Push Point n Other <br /> Proposed Well Depth�_ft Excavation in diameter Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickne7N� <br /> auge/ASTM Sched Steel Plastic ❑ Stainless Steel Other <br /> Grout Seal Depth ft at Cement(94/b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) - Other <br /> Grout Placement Method -- Pumped iJ Free Fail Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ❑ Pump Contractor - Other <br /> Concrete Pedestal❑Dlmenslons:Width It Length ft Thick in Christy Box Stove Pipe <br /> PUMP - Submersible,i Turbine -1 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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209)953-7697 <br /> SIGNED -L LSI P2,__j TFTLE -Lu X v �-- DATE <br /> I <br /> aS <br /> N <br /> TV I <br /> ———tF <br /> R <br /> D PA TMENT 7� E NLY <br /> Application Accepted By _ Date Area Employee ID# <br /> Grout Inspection By Date Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Z 541 Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chec Amount PermiU <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />