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NA IQs i6� <br /> 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 /> I,�� / rn <br /> JOB ADDRESS c� / y!�z �l$t lti Vv�^M CITY/ZIP ��"G k"tUy� i l� / j y LU m <br /> �I r I^r G Ac MS D <br /> CROSS STREET �`�q� kt CiVa l" APN (S 3� I& PARCEL SIZE � 4 LAND USE APPLICATION# <br /> �,/ m <br /> OWNER NAME �_tR1 `/ PHONE y <br /> N <br /> OWNER ADDRESS 1,4z11 �j CITY/STATE/ZIP ( 9 ) —j z 7 <br /> CONTRACTOR of f CC�O- 7 v1 <br /> 35 it '{t�rt 1�`lp0�61 t 01 k,�i5 i/I f 2S ( PHONE/ /�1� 1 / 3 6 1 l I E I <br /> �Z �MNK$t( C� WOL� CITY/STATE/ZIP lh0Cti CA / 9524"0 <br /> CONTRACTOR ADDRESS 9 r <br /> SUBCONTRACTOR/CONSULTANT N/A PHONE/^ N/A <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 1\t/A CITY/STATE/ZIP <br /> LICENSE �*: C-57 C-61 D-09 Other NUMBER <br /> v 00 I EXPIRATION DATED s/-� 1 / Z-0 Z 1 <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring X 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 Replacement Well Well Alteration/Modification Other <br /> _ Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical j #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method X. Mud Rotary Air Rotary XAuger, 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 tThickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft X Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Othe Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible_ Turbine 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 /> a53-769 <br /> SIGNED �" l it' I TITLE I f �✓LQ(AE-er DATE DEC 2,0It� <br /> It t <br /> CAI <br /> .r <br /> T <br /> F— <br /> 1 <br /> C. <br /> Q r <br /> T <br /> DEiiARTMENT SE NLY <br /> Application Accepted By Date Area . �'uF .__ Employee ID# <br /> M" <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received k# Amount Permitl <br /> Codes Info B Cash emitted Date Service Request# Invoice# Well ID# <br /> 2 'U \ <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />