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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///�_ J�, WWW.S ov.ol /ehd EXPIRES 1�YEEAR FROM DATE ISSUED <br /> JOB ADDRESS / i— /l � ��C, CITY/ZIP C fY14/ei r m <br /> �c,� <br /> APN �( D <br /> CROSS STREET ,{ /// ARCEL SIZE LAND USE APPLICATION#( <br /> OWNER NAME C..l—/'t b©�A (!l PHONE / —3 ✓ �� ��+ <br /> OWNER ADDRESS WL Cir/ r CITY/STATE/ZIP 64 C• <br /> CONTRACTOR 44A_6/-V:U '0 PHONE <br /> CONTRACTOR ADDRESSROS Z,/ 7k CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT�J'�/I7pl PHONE _ <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP / <br /> LICENSE ❑ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER '3-7 73OVr EXPIRATION DATE <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:I .General Mineral/Coliform Bacteria(4391) ' Dibromochloropropane(4392)• Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private rigation/Agricultural D Industrial ❑ 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 U Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> LI Out-Of-Service Well ❑ Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> PsNew Pump ❑ Pump Replacement ❑ PUrnp Repair rJ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method AMud Rotary ❑ Air Rotary D Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth TCO ft Excavation jL in diameter CI Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing DiameterIn Thickness/Gauge/ASTM Sched.2&.2 ❑ Steel (t Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth f— <br /> _ft ❑ Neat Cement(94 lb bag/5-10 gal water) AsanciCement /0'�3 sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other _ <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other IJ Retardant/Accelerator(name) <br /> PEDESTAL Installed By IkDfiller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal DDimensions:Width,L_ft Length ft Thick__4_in ❑ Christy Box ❑ Stove Pipe <br /> PUMP J<SubmersibleEl 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 /> MINIMUM/48 HOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)/953-769/7[ <br /> SIGNED x Y� _ TITLE // ����L DATE Z j <br /> ,y <br /> A q <br /> r <br /> E eARTMENT U E O LY <br /> 1 <br /> Application Accepted By DateI Area Employee ID#� <br /> Grout Inspection By_ Date SPECIAL Well Permit <br /> Pump Inspection By �_. , �_ vl� Date ZO2C WAIVER Received <br /> Soil Boring Inspection By Date _ /Constructed We[I ft <br /> COMMENTS '/✓�Qi L Q _S_� �J11/OI.tCA.I��(1(.fZr1 O�'�'_ f'L i <br /> PE Sc Received Amount Permit/ <br /> Codes Info B Cash emitted Date Service Re uest# Invoice# Well ID# <br /> 102 - q <br /> �- <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />