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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 /> �1 s � <br /> JOB ADDRESS I�env 2[y S� SDV'C( �µft� ��✓ D� SJ 7 6• CITY/ZIP T�7`O-I �S. I m <br /> CROSS STREET D 0"IAPN Z0r3fJ'V f?0-000 PARCEL SIZE/��G• LAND USE APPLICATION# <br /> An <br /> OWNER NAME TKgi� O n t(„L PHONE& LZ4,7.0bo <br /> OWNER AD R�ES <br /> 54�+CL�tt�lE f% _/00 CITY/STATE/ZIP�JEb✓�/Olif �C�8'660 <br /> _ <br /> (.tiALLAC E— kutu PHON �I�Qi T7�—/yef r Q <br /> RAD ESS ?05 X110✓j /f+/�l +�b CITY/STATE/ZIP W J4L G�7��/ <br /> T' �R-�4L�'1� �i✓C PHON/%,P � pL,,*-7? 0 <br /> 0 <br /> pp <br /> SUBCONTRACTOR/CONSULTANT ADDRESS �tL44k&4,W_ CITY/STATE/ZIP AA4—&Tte « <br /> LICENSE ;C-57 Cl C-61 1:1D-09 U Other NUMBER 7ZO"ZIEXPIRATION DATE O�Z� <br /> BILLING PARTY: OWNER ONTRACTOR UBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:! 1 General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial 11 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 fl New Well U Replacement Well U Well Alteration/Modification U Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings 3V/Geotechnical---� _#of borings <br /> ❑ Out-Of-Service Well U Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> U New Pump 0 Pump Replacement ❑ Pump Repair U Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth/0-TO ft Excavation e—B 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 U Steel U Plastic U Stainless Steel U Other <br /> Grout Seal Depth ft )e Neat Cement(94 lb bag/5-10 gal water) U Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method U Pumped A Free Fall JQ Other Ti.IrMlk If N ❑ Retardant Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller U Pump Contractor ❑ Other <br /> U Concrete Pedestal[I Dimensions:Width ft Length ft Thick in ❑ Christy Box 0 Stove Pipe <br /> [PUMP U Submersible[] Turbine U Other HP Pump Set ft Standing Water Level ft <br /> 1 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 /> MINI 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209) 95,3-7697 <br /> SIGNED _ TITLE_,f'/4 rF 1r40t'OCi{P_ DATE / <br /> fy� V� <br /> N �Y <br /> DEP RTMENT USE ONNLY <br /> Application Accepted By Esc Date % Area 5AWV_ Employee ID# A <br /> Grout Inspection By _ Date_ SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By - Date z0� Constructed Well Depth <br /> COMMENTS <br /> PE SC Received a Amount ate Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Re uest# <br /> a <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />