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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 /> r 1 �' <br /> JOB ADDRESS c.`T GI KC WAV CITYTZIP m <br /> Jf D <br /> _ 1 /LAND USE APPLICATION# A <br /> CROSS STREET I tf11 nVr �� APN -I, '' V�PARCEL SIZE/ �1 m <br /> OWNER NAME �J ' �0 � I� PHONE <br /> OWNER ADDRESSJ 1 CITY/STATEIZIP�Cn,. C'i...�� �`�^�� <br /> d I I <br /> CONTRACTOR PHONE <br /> a <br /> CONTRACTOR ADDRESS .F11 9A CITYISTATE21P <br /> SUBCONTRACTORICONSULTANT YT � �Y�® 'A PHONE �0L 0C' <br /> �■ <br /> SUBCONTRACTORICONSULTANT ADDRESS—# ��k-aw—, CI Y/STATEIZIP J' arL'Al ZO9 V'CS <br /> LICENSE VC-57 D C-61 D D-09 0 Other NUMBER EXPIRATION DATE q <br /> BILLING PARTY: O OWNER \O CONTRACTOR 0 SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:D General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural D Industrial D Water Quality Monitoring oll 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 0 Replacement Well D Well Alteration/Modification 0 Other <br /> D Monitoring Well(s) #ofwells DSoilBoring(s) #of borings ,eotechnical .12 eofbonngs <br /> D Out-Of-Service Well D Out-Of-Service Well Renewal D Cross-Connection Repair <br /> D New Pump 0 Pump Replacement D Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION � <br /> Drilling Method D Mud Rotary C Air Rotary U Auger D Cable Tool Push Point C Other <br /> Proposed Well Depth It Excavation in diameter 7 Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> I I Condu or Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter n Thickness/Gauga/ASTM Schad 7 Steel 7 Plastic 0 Stainless Steel D Other <br /> Grout Seal Depth It N-Beat Cement(94 Ib bag/5-10 gal water) -1 Sand Cement sack mix1`7 gal water <br /> D Bentonite(20%solids) C Other <br /> Grout Placement Methodl**6umped C Free Fall Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller D Pump Contractor 7 Other <br /> U Concrete Pedestal UDimensions:Width It Length ft Thick in L Christy Box L Stove Pipe p <br /> AyME <br /> PUMP I I Submersible I Turbine I Other HP Pump Set ft Standing Water Level <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALLNOVa•m <br /> WORKERS COMPENSATION LAWS. I/ <br /> MINI M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SSq JO ��1/� <br /> SIGNED TITLE �Tf Ija"I�, 0 0 DATE r-VV/AQV/N <br /> CTy p pM�^��Iy <br /> T <br /> =AR' NT U LY <br /> Application Accepted By to Area Employee <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By on Date ❑ WAIVER Received <br /> Soil Boring Inspection B Date Constructed Well Depth ft <br /> COM ENTS f <br /> K <br /> PE It SC Received Check#/ Amount Date Permit) invoice# Well ID# <br /> Codes Info Cas itte S ice Re uest# <br /> EHD43-06 6111r2019 /V/02f7 T/7 WELL/PUMP PERMIT <br />