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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-REFUNDABLE PERMIT�y www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS /,`� W _rw(NQr PW 0*.d"&'rA IG CITYIZIP Z.0,4 j Ci 159 m <br /> CROSS STREET C..114?/'0IM10-- ALP�N N!T`` PARCEL S¢EN LAND USE APPLICA1TION# p <br /> OWNER NAME CI+-ra A C. ^��,/,�LJ(�T /G '/ PHONE /� '�DZ7 1 �! <br /> 1 �f �1 �— <br /> OWNER ADDRESS -�l Y1 6- -Li f��/� .tIw/Vl�/ CITY/STATE/ZIP�. J�,Q r-A 16]Zo <br /> -'r <br /> CONTRACTOR W I 1 I—� PHONEl�►(� •"'� <br /> CONTRACTOR ADDRESS 1 Drive- CITY/STATEIZIP&4J 7/ G <br /> ir A 154g 5Z <br /> SUBCONTRACTORICONSULTANT Ge�O & 1.01A¢ PHONNE�f25)/�3,�-/I-5C100 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS (o6� g/I 1�SA ST7�J CITY/STATE/ZIP L-4W-r N(BIC� L/T9�SSQ <br /> LICENSE C-57 =C-61 D-09 -Other NUMBER W..]Q� E%PIRATON DATE <br /> BILLING PARTY: -OWNER -CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:7 General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)-Arsenic(4393) <br /> INTENDED USE L Domestic/Private Irrigadon/Agricultural 1_Industrial -Water Quality Monitoring Soil Sampling/Characterization <br /> C Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK L New Well _ Replacement Well Well Alteration/Modification Other <br /> L Monitoring Well(s) #of wells -Soil Boring(s) #of borings XGeotechnical 41 of boo- <br /> -Out-Of-Service Well -Out-Of-Service Well Renewal _Cross-Connection Repair <br /> L New Pum - Pump Replacement -Pump Repair - Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method L Mud Rotary -Air Rotary (Auger _ Cable Tool -Push Point Other <br /> c. <br /> Proposed Well Depth * ft Excavation-!V _in diameter L Open Bottom L Gravel Pack/Gravel Size in diameter <br /> L Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched -Steel - Plastic Stainless Steel _Other <br /> Grout Seal Depth 'L(2' ft X Neat Cement(94 Ib bag/5-10 gal water) _Sand Cement sack mix/7 gal water <br /> C Bentonite(20%solids) -Other <br /> Grout Placement Method L Pumped jt Free Fall - Other -Retardant/Accelerator(name) <br /> PEDESTAL Installed By - Driller - Pump Contractor - Other <br /> L Concrete Pedestal-Dimensions:Width It Length ft Thick in -Christy Box -Stove Pipe <br /> PUMP C SubmersibleC Turbine Other HP Pump Set It Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIV ITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPEN N LA <br /> MINIM ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE O DATE <br /> RA YMENr <br /> C�jVEC <br /> 30201, <br /> ORON/N COUNTY <br /> TH D.,AR AdS7AL <br /> DEP RTMENT7U ��/� `/ <br /> Application Accepted By Date/G- 30 Area 1^ Employee ID#S' -lJ��`( <br /> Grout Inspection By Date _ SPECIAL Well Permit <br /> Pump Inspection By A 11 P, Date - WAIVER Received <br /> Soil Boring Inspection yAkw Dat , Z-6Z� Constructed ell eptIt ft <br /> COMMENTS �)E V I <br /> d <br /> 0te C Ag ho.ars- <br /> PE Sc Received Check#/ Amount PermiU <br /> Codes Into B Cash Remitted Date Service Re uest# Invoice# Well ID# <br /> _t'. I •� '' <br /> EH043.06 811112019 WELL!PUMP PERMIT <br />