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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> jo r rn <br /> JOB ADDRESS \ S CITY/ZIP V2 m <br /> CROSS STREET` 3 M� yV O VI , 1 APN A 0 5 - 36 v I�PARCEL SIZIi��AND USE LP(LLICATION#I� A <br /> OWNER NAME s PHONE <br /> OWNER ADDRESS CITY/STATE/IJ �J <br /> CONTRACTOR PH/OINE_} -3 '�-7-'/-� <br /> CONTRACTOR ADDRESS CITYISTATE/ZIP �(/I I I � <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP 2 <br /> LICENSE C-57 C-61 D-09 Other NUMBER 3 EXPIRATION DATE 3 <br /> DoMEsnc WELL SAMPLING: General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE XDomestic/Private Irrigation/Agricultural Industrial 0 Water Quality Monitoring 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 0 Well Alteration/Modification 0 Other <br /> Monitoring Well(s) #of wells 0 Soil Borings) #of borings Geotechnical #of borings <br /> Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> New Pump Pump Replacement 11 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method X Mud Rotary Air Rotary Auger 0 Cable Tool Push Point 11 Other <br /> Proposed Well Depth x-75 ft Excavation—12-- in diameter 11 Open Bottom XGravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched(- I Steel Plast c i Stainless Steel Other <br /> Grout Seal DepthI n�ft Neat Cement(94 Ib bag/5-10 gal water) }(Sand Cement I h, sack mix17 gal water <br /> Bentonite(20%solids) Other �Ay 41Z1V7' <br /> Grout Placement Method X Pumped Free Fall Other -Retardant/Accelerator(name) <br /> PEDESTAL Installed By K Driller Pump ContractOther <br /> Concrete Pedestal Dimensions:W dth ft Length ft Thick 1,Q in Christy Box Stove Pipe A10 l�o� 9 <br /> PUMP Submersible Turbine Other HP Pump Set It Standing Water Level f r 3 200 <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SA v <br /> CENSE IS <br /> CURRENT AND ACTIVE OA <br /> JOAQUIN COUNTY IWITH THE SCAIFORNIA CONTRACTORS STATE TATE LAWS, AND RULES AND UICE SE BOARD AND LATIONS. I ALSO THAT I AM IN COMPLIANCE TIFY THAT MY REQUIRED (WITH AENTAL <br /> l�lfr- NV)RpNMOOUN7Y <br /> WORKERS COMP MS 8 HNUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 LT N DEa�2 SENT <br /> 1n <br /> SIGNED % -1 ' ' TITLE DATE <br /> IL <br /> t <br /> O*Grout <br /> MENT SE ONLYApplication Accepted By ate C 2- Area Employee ID# <br /> Inspection ByDateSPECIA Well PermitPump Inspection ByDate -J 7 ,'1 WAIVER Received <br /> Soil Boring I spection By Date C ��ucted II Depth It <br /> COMMENTS �1/ <br /> PE Sc Received ;'Checw Amount Date Penult/ Invoice# Well IDN <br /> Codes Ifo ash Remitted Service Request# <br /> EHD 43-06 revised 4/14/19 WELL/PUMP PERMIT <br />