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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.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS +649 MDntaa CITY/ZIP / 04 /�/�� m <br /> CROSS STREET _APN aK-/ /O ✓J� PARCEL SIZE Le- I LAND USE APPLICATIONG_� A <br /> OWNER NAME m <br /> PHONEO-M-6w <br /> 4vAOWNER ADDRFSS E CITY/STATE/ZIP ��9y L.I_r fSCJC OI <br /> CONTRACTOR l PHONEC.XIl �' <br /> CONTRACTOR ADDRES CITY/STATE/ZIPI� V <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRAC R/CONSULTANT ADDRESS TY/STATE/ZIP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 Ll Other NUMBERA�W�a EXPIRATION DATE 1313 <br /> " <br /> BILLING P RTY: OWNER !1 CONTRACTOR i SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SA PLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE X,Domestic/Private ❑ 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 ❑ New Well D Replacement Well D Well Alteration/Modification CI Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #or borings ❑ Geotechnical_ #of borings <br /> ❑ Out-Of-ServiceAP <br /> II ❑ Out-Of-Service Well Renewal D Cross-Connection Repair <br /> 11 New Pump um Replacement ❑ Pump Repair— ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary D Air Rotary I] Auger ❑ Cable Tool ❑ Push Point ❑ 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 Thickness/Gauge/ASTM Sched ❑ Steel 11Plastic D Stainless Steel ❑ Other <br /> Grout Seal Depth_ ft ❑ Neat Cement(94/b bag/5-10 gal water) LI Sand Cement sack mix17 gal water <br /> I] Bentonite(20%solids) ❑ Other <br /> Grout Placement Method r] Pumped 0 Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> D Concrete Pedestal DDimensions:Width ft Length ft Thick in ❑ Christy Box 0 Stove Pipe <br /> rPump I Submersible❑ Turbine 0 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 /> JOAQUI UNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRE A D ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKE S C MPENSATI N L S C,► <br /> MI N 48 UR T RE U RED FO NSPECTI NS-PLEASE CALL(209)953-77 77 r, <br /> SIGNED _ _ TITLE DATE <br /> 17 — 19 <br /> Ca(Yd I I - Q171 <br /> / <br /> M Tr <br /> T <br /> t <br /> O <br /> 9�Late <br /> ENT U E N LApplication Accepted By -.1 Area /imEmployee ID# <br /> Grout Inspection By _ Date_ I I PECIAL Well Permit <br /> 2 <br /> Pump Inspection By r4 Date 1I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received/ (?thecyK Amount Date Permit/ Invoice# Well ID# <br /> Codes Irrfo B sh Remitted Service Request# <br /> Cp <br /> la ( 0 <br /> EI-ID 43-06 6/11/2019 WELL/PUMP PERMIT <br />