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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZFLTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT 1VVVVvV.S. <br /> OV.O /ehd EXPIRES 7 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I- W, CITYIZIP <br /> CROSS STREET"C)`��IYIY►\CLn 9, /'� APN t�'h-C�zC �t PARCEL SIZE J, a1 LAND USE APPLICATION# <br /> OROWNER NAME /�{� © LL`��J� PHONE <br /> OWNER ADDRESS 3�yoQ/� I /rlCITY/STATE/ZIP <br /> CONTRACTORH�l�S�dc ((\\T'}y�l PHONE(2� <br /> ICA `y <br /> CONTRACTOR ADDRESS ` � JOX \�U(' _ CITYISTATEIZIP \rCC.�� ICA <br /> SUBCONTRACTORICONSULTANT MIC\p,t\`4.\CIL A\�Ny\-'tti iq PHONE `` <br /> SUBCONTRACTORICONSULTANT ADDRESS \J 1� �`M�Tr�'(C-LLAlrW \J Y'\r' ((CC�IITyyYI�SST��ATI0 <br /> 'tE� P,,�tz\'r C W <br /> LICENSE 91/C-57 0 C-61 C D-09 D Other NUMBER W EXPIRATION DATE <br /> BILLING PARTY: 7 OWNER D CONTRACTO�UBCONTRACTORICONSULTANT <br /> DOME"C WELL SAMPLING:D General MinerallColiform Bacteria(4391)0 Dibromochloropropane(4392)D Arsenic(4393) <br /> TENDED USE 0 DomesticJPrtvate C Irrigation/Agricultural D Industrial D Water Quality Monitoring Soil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF.WORK C New Well D Replacement Well O Idlell Alleration/M^a' ion 0 Other <br /> D Monitoring Well(s) #of wells /Soil Bodng(s) 4 of borings IVGeotechnical L9 of—aa <br /> 0 Out-Of-Service Well C Out-Of-Service Well Renewal 0 Cross-Connectlon Repair <br /> 0 New Purnp ❑Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> ,Drilling Method D Mud Rotary 0 Air Rotary VAuger ❑Cable Tool ❑Push Point 0 Other <br /> Proposed Well Depth IS Excavation—LL—In diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in ThicknesVGauge/ASTM Schad ❑Steel ❑Plastic 0 Stainless Steel ❑Other <br /> Grout Seal Depth l5 11 4 Neat Cement(94/b bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br /> D Bentonite(20%solids)) ❑Other <br /> Grout Placement Method ❑Pumped V Free Fall 0 Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By C Driller 0 Pump Contractor ❑ Other <br /> ❑Concrete Pedestal ODimenslons:Width_It Length ft Thick in 0 Christy Box C Stove Pipe <br /> PUMP D SubmerslbleD Turbine C Other HP Pump Set. _ It Standing Water Level it <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 COMPEN ON LAWS. <br /> MINIMUM 4 H R AD NCE NO E QUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE L,J�1.1Y\GY 'MANN,&&. DATE 7-OX <br /> I I <br /> �Nr <br /> I �Eo <br /> ' o <br /> r <br /> aA TMENT U E NLY <br /> • <br /> Application Accepted By Date v"� Area Employee ID# <br /> Grout Inspection By Date 0 SPECIAL Well Pertirllt <br /> Pump Inspection By Date G WAIVER Received <br /> Solt Boring Inspection By Date r —24f Constructed Well Depth tt <br /> COMMENTS <br /> PE SC Received Chat: I Amount Permit/ <br /> Codes Info B ash Remitted- Date _ Servi �ue_st#Permit/ Invoice Well ID# <br /> I <br /> EH043-06 6/11/2018 WELL/PUMP PERMIT <br />