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r <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 ,I twww.s OV.Of /ehd EXPIRES�j1 YEAR FROM DATE ISSUED <br /> r <br /> JOB ADDRESS A Y 1�p 4-IC-VY CITY/ZIP ` , 44 V"7 c)53F. <br /> CROSS STREETlZG t <br /> "}� y^� APN�V7 c� I-t-�PARCEL SZE IL_LAND US�E_APPLIC�A5TION/# <br /> bo3O 0 <br /> AU- <br /> LA <br /> �p <br /> OWNERNAME `Vr,i .Ay P PHONE 4�1OWNERADDRESS 102"S1 CfTY/STATE/ZIP L-ATgjj&:!?t CA- <br /> CONTRACTOR <br /> CONTRACTOR �+Nkf PHONE2_09 469 <br /> CONTRACTOR ADDRESS L '_^ CITY/STATE21P 1 1 coAr <br /> SUBCONTRACTORICONSULTANT CAJSV�—jAjt-I PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS 12&� lQM_r5A�!;�r �m? <br /> CITY/STATE/ZIP <br /> LICENSE DlC-57 11C-61 n D-09 G Other NUMBER EXPIRATION DATE +-36 -I—VU) <br /> BILLING PARRTY` D OWNER CONTRACTOR X SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑Irrigation/Agricultural E Industrial C Water Quality Monitoring XS.oil Sampling/Characterization <br /> []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 C Other w <br /> C Monitoring Wellg #of borings s) #of wells ❑Soil Boring(s) #of borings r <br /> [] Geotechnical Z� c <br /> L Out-Of-Service Well D Out-Of-Service Well Renewal C Cross-Connection Repair ^ ///���... <br /> New Pum C Pum Replacement D Pum Repair G Raise Well Casing � <br /> v prl <br /> WELL CONSTRUCTION <br /> Drilling Method []Mud Rotary G Air Rotary >auger (iICable Tool C Push Point G Other 02202 <br /> Proposed Well Depth _W Excavation in diameter C Open Bottom C Gravel Pack/Gravel Size it e 0 <br /> C Conductor Casing in diameter / Conductor Casing Depth It H ENV Q�IN C N <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel D Plastic C Stainless Steel G Other N) ENTN Ty <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> C Bentonite(20%solids) C Other RTINENT <br /> Grout Placement Method C Pumped gree Fall C Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By C Driller ❑ Pump Contractor C Other <br /> C Concrete Pedestal❑Dimensions:Width It Length ft Thick in E Christy Box G Stove Pipe <br /> PUMP D 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 CO ENSATIO I LAWS. <br /> IA M 48 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> -P EASE CALL(209)953- 69�7J <br /> SIGNE �- TITLE G�:V\JI DATE ✓/�V <br /> DEPARTMENT U E ONLY <br /> Application Accepted By Date Z�'t� Area t"4 'Employee I D# rf <br /> Grout Inspection By Date �'2-40' 7 PECIAL Well Pefflllt <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring I s ection By Date Constructed W 11 D th ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Arvice Request# <br /> EHD43-06 6/11/2019 l�6;-70Z3 <br /> — 70Z3 WELL/PUMP PERMIT <br />