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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.sigov.org/ehd EXPIRES YEAR FROM DATE ISSUED <br /> q yy '7 <br /> Joe ADDRESS / r G CITY/Zip �P I r� d /O 0 <br /> CROSS STREET Pu lr xk �.G APN �S 7'�I I% L�0 PARCEL SIZE LAND USE APPLICATION# O <br /> OWNER NAME �P,W J E ru`7 a►rJ wre�"fn7F R/ �C �( I�1I�'� PHONE <br /> OWNER ADDRESS Iiwli <br /> (J� � ► CITY/STATEZP r4 <br /> CONTRACTOR 11V4� <br /> PHONE G�f � /�p/S' <br /> CONTRACTOR ADDRESS t" v `/`�G X 1 CITY/STATEZP(- C �G✓I �'!±Z C�'• 1 �'7y <br /> SUBCONTRACTOR/CONSULTANT J-0(.Th /x'117 r1 h'1�j —P (I VL PHONE D /� /j/�[ ✓OJ�l <br /> Wt 110 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS N'D lI I W�`�rM �Jr' �7 (�I UL t CITY/STATE/ZIP <br /> � / `/2-t J / 7 <br /> LICENSE A57 C-61 D-09 Other NUMBER -D 6 EXPIRATION DATE I 3 202Z) <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT A�a_ <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) 1c � <br /> INTENDED UsE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Sail Sampling/Characterization Ciy jV�� <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 Ce.. 2020 <br /> A o0 <br /> Monitoring Wells) #of wells Soil Boring #of bonngs s) Geotechnical� f borings FNV► QU/►V(,` <br /> Out-Of-Service Well out-Of-Service Well Renewal Cross-Connection Repair 77C /1�rH O/�MFtiT�NTS <br /> New Pum Pum Replacement Pum Repair Raise Well Casin �L r I <br /> WELL CONSTRUCTION EPgRTI 4 <br /> 6NT <br /> Drilling Method Mud Rotary I Air Rotary )Auger Cable Tool Push Paint Other <br /> Proposed Well Depthjf3e50 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 iry Thickness auge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth b ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mW7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall ther Retardant I 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 /> M IMUM 48 H ADVrCE NOTICE REQUIRED F(r INSPECTI N -PLEASE CALL(209)953-769 <br /> SIGNED r TITLE ns,+rt 7)Q DATE 0' 13 12P ZZ <br /> VE® <br /> 020 <br /> L HEALTH <br /> I Ft RMITASEE VICES <br /> A MENT VSEIONLY //,p} <br /> Application Accepted By ate Area``{ Employee 14,ILW I wJ <br /> Grout Inspection By Date SPECIAL Well Permit PPP"'TT�"���^^^ <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection Byate Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received hec Amount Permit/ <br /> Codes Info s mi ed Date rvice Re u st Invoice# Well ID# <br /> O t <br /> EH043-06 6/11/2019 WELL/PUMP PERMIT <br />