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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-nFU_NPABLE PERMIT \ www.sjgov.org/ehd EXPIRES'I YEAR FROM DATE ISSUED <br /> JO E �7rC] CITY21P f U m <br /> D <br /> CROSSSTREET 1n�—'^ex!a APN�al2E 001 PARCEL SIZE.1.5 LAND USE APPLICATION# 0 <br /> OWNER NAME - CY'Ft6�6.4'�-,la uQ PHONE �� ��I� P•' <br /> OWNER ADDRESS '� in cloy -sy/ �CIITYISTATEIZI—P/ ��_ :5._ 6 <br /> r yr <br /> CONTRACTOR 1,(1 A I J n I J_�.`` �pt (p n` PHONE�a-IfQ1 Q 1: �1�P 4 <br /> CONTRACTOR ADDRESS�_�/�++ ��(y.N'l t�`OYk 1`W le6 CITY/STATE21P cnUt �/ -- n� <br /> SUBCONTRACTOR/CONSULTANT Y'T�.i� �Y��M� PHONE�Q _,194653 <br /> )'� " '9S 06 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS UaNi6 CnY/STATE21P M cAi/1 pZ/K_ 19 4 65 1� <br /> LICENSE V47 ❑C-61 ❑D-09 D Other NUMBERD L11 EXPIRATION DATE— -304- <br /> BILLING PARTY: D OWNER IZ CONTRACTOR D SUSCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:D General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)D Arsenic(4393) <br /> INTENDED USE ❑DomestlC/Pdvate D Irrigation/Agricultural ❑Industrial D Water Quality Monitoring krtoil 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 ❑Replacement Well ❑Well Alteration/Modification D Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings }l�<eotechnical #of borings <br /> ❑Out-Of-Service Well D Out-Of-Service Well Renewal D Gross-Connection Repair <br /> D New Pump ❑Pump Replacement 7 Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary C Air Rotary 7 Auger ❑Cable Tool '"!Push Point C Other <br /> Proposed Well Depth ft Excavation in diameter 7 Open Bottom D Gravel Pack/Gravel Size in diameter <br /> i 1 Condu or Casing In diameter / Conductor Casing Depth ft <br /> Well Casing Diameterin Thickness/Gauge/ASTM Schad :1Steel 7 Plastic D Stainless Steel D Other <br /> Grout Seal Depth ;j_� It eat Cement(94 Ib bag15-10 gal water) -1 Sand Cement sack mix/7 ga$W.atj <br /> D Bentonite(20%solids) C Other Grout Placement Methodlir�umped C Free Fall Othe C Retardant/Axelerator(name)PEDESTAL Installed By D Driller D Pump Contractor 7 OtherU Concrete Pedestal I.1Dimensions:Width ft Length ft Thick in LChristyBox LStovePi 6 <br /> PUMP I 1 Submersible I Turbine I Other HP Pump Set ft Standing Water Level 201,9 <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDAN(� •F <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED Vl^y CUV <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE W �A <br /> WORKERSMP RT <br /> M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> MINI �FMT <br /> SIGNED r/ TITLE DATE <br /> DATE <br /> 1#1 1 1 <br /> PA TMENT U / NLY <br /> Application Accepted By Date v Area�/ Employee ID# ji.�X/1 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By A I Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/Codes Info Cas Remitted Date Se ice Raonest# Invoice# Well ID# <br /> EHD43-00 0/1112019 /p/o.2--FS-4 i WELL/PUMP PERMT <br />