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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 <br /> JJP PERMIT www.sjgov.org/ehd EXPIRES <br /> 11YYEEAR FROM DATE ISSUED <br /> JOB ADDRESS �li{/ CITY/ZIP m <br /> / <br /> CROSS STREET t , ff II D <br /> �/�/��N Q PARCEL SIZE BLAND USE APPLICATION# p <br /> m <br /> OWNERNAMEG` _ PHONE /JO / 7 ren <br /> / � ,jam_-� two/► /�/f�Q�//T�r� e�( 4 <br /> OWNER ADDRESS p/�A -;Fie �/-�/�/t�J-� CITY/STATE/ZIP /&/`•_ T)-y, I- e77 -[7 <br /> CONTRACTOR / C c//` may/` �„j i%S� PHONE <br /> CONTRACTOR ADDRESS !�^�Zp til/�1-�(�k- /2�� CITY/STATEIZIP <br /> e <br /> SUBCONTRACTOR/CONSULTANT L�S W44 PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS - CITY/STATE/ZIP ^ _/ <br /> LICENSE 0-57 OC-61 I I D-09 U // tt/Other NUMBER_�G EXPIRATION DATE----./ rizl <br /> BILLING PARTY: 'OWNER AVC:ONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: eneral Mineral/Coliform Bacteria(4391) bromochloropropane(4392) Arsenic(4393)PqY <br /> INTENDED USE XIDomesti6lPrivate ❑ Irrigation/Agricultural rl Industrial ❑ Water Quality Monitoring ❑ Soil vPA440AFT I- <br /> ❑ Public Water System <br /> If different from Owner- Water System Name Contact Name or Phone Numb" <br /> TYPE OF WORK ❑ New Well 1WReplacernent Well ❑ Well Alteration/Modification ❑ Other <br /> UV <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical_ FN O,4(:U/}� s <br /> IJ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair -SAI_y�ONMFNTgI TY <br /> New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing EPA �E�T <br /> WELL CONSTRUIETION <br /> Drilling Methodj0i0Mud Rotary ❑ Air Rotary ❑ Auger n Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth�.�f!— Excavation 147— in diameter ❑ Open Bottom lektravel Pack/Gravel Size in diameter <br /> r_I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched aG 7 ❑ Steel.0lastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth 1,V ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) U Other <br /> Grout Placement Method umped ❑ Free Fall ❑ Other ❑ Retar ant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑13mensions:Width ft Length ft Thick in U Christy Box U Stove Pipe <br /> PUMP Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level_ <br /> 1 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 RPEQUIRED 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 /> MIt _OANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)/963-76997//jJsy <br /> SIGIE _ TITLE S%�%-�C DATE <br /> D --c <br /> f ! <br /> 6 ` <br /> s <br /> B � <br /> 1 <br /> �e.FE-1.4 <br /> -EPARTMENT USE ONLY <br /> r <br /> Application Accepted By Date Area s� <br /> / yee ID# <br /> Grout Inspection By " Date ( EECIAL Well Permit <br /> Pump Inspection By �t-ouw•51e CD-PWt, 1,:&Li Date Zl �D IZ0q.,y WAIVER Received <br /> Soil Boring In ection By Dae Constru ted Well Depth _ft <br /> UM <br /> NTS <br /> — �0O Z ---- - — <br /> PE Sc ReceivedChec Amoun Date Permit/ Invoice# Well ID# <br /> Codes Inf ash Remitted Service Re uest# <br /> 4970 d& s 7 WPOO40 15 <br /> O <br /> 9t) 3-06 6/11/2019 WELL/PUMP PERMIT <br />