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t <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENInRoNMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www-sjgov.org/ehd EtXPIRESn1 YEAR FROM DATE ISSUED <br /> If .01 <br /> JOB ADDRESS 7cJtJ J�7 G1(T CffYIZIP��J"1 ��/! 5`.33t!✓ m <br /> CROSS STREET APIN (J Jv PARCEL SL�� IJ <br /> IA n USE APP�C)ATION <br /> OWNER NAME U `' r/✓J "G�jC- �t PHONE ✓y'�6L YG�J�)"'r/� �. <br /> OWNER ADDRESS _ �l�/r I.`C� �T V L� CITY/STATERIP <br /> CONTRACTOR n "r PHONE <br /> CONTitACTOR ADDRESS / CITY/STATE/ZIP 0f J r <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT -RESS 1 CITY/STATFIZIP <br /> LICENSE L C-57 -61 D-09 E Other DMZ t NUMBER/0,5;Z�75- FjtpIRATION DATE <br /> BILUNG PARTY: C OWNER tlCONTRACTOR SUBCONTRACTORICOKSULTANT <br /> DOMESTIC WELL SA!P G:L General MinerallColiform Bacteria(4391)-1 Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE 0-''DomesticJPrivate G Irrigation/Agricultural 7 Industrial Water Quality Monitoring �Soil Sampling/Characterization <br /> =Public Water System <br /> If tlillerel I Imm Owner. Water System Name Contact Name or Phone Number <br /> TYPEOF WORK ew Well _Replacement Well -Well Afteration/Modificalion -Other <br /> 7 Monitoring Well(s) # Its =Soil Boring(s) tt en,Unln'' C Geotechnical c or borings <br /> Out-Ol-Service ell G Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum [I Pump Repair -Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary =Air Rotary ❑Auger Cable Tool L Push Point _ Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> -Conductor Casing in diameter I Conductor Casing Depth tl <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched :]Steel Plastic C Stainless Steel =Other <br /> Grout Seal Depth It 71 Neat Cement(94 Ib bag/5-10 gal wafer) ❑Sand Cement sack rt/x77 gal water <br /> Bentonite(20%solids) ,Other <br /> Grout Placement Method Pumped C Free Fall 7 Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Drillerump Contracto IOther <br /> _]Concrete Pedestal❑Dimensions:Width ft Length ft Thick in I"!Christy Bo: Stove Pipe <br /> nc <br /> PUMP ubmersible Turbine ❑Other HP= Pump Set ft Standing Water Level ' _.. 0 <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 99MPENSATION LAWS. <br /> D;r 'Y HO ADVANCE NO TICE REQUIRED FOR tNSPECC T ttONS-PLEASE CALL(tui <br /> e <br /> SIGNE TITLE(. �l� rt DATE �Jf� •,/ <br /> 1 <br /> 1 <br /> i <br /> 1 . <br /> CIVP <br /> ; :.s 'D <br /> T - - - ou <br /> N jj$AjU0AQujN(RoNvm cCT Nom' <br /> H DEpA'RTMENT <br /> D PA YT M E N T USE ONLY ,�w} <br /> /99 Application Accepted By Date ea� Employee ID# ,�#J <br /> Grout Inspection By Date SPECIAL WCII Permit <br /> Pump Inspection By r ilf ci-1i.S i., �"^�• �'�-.rL Date :1 WAIVER Received <br /> Soil Boring Inspection By �LDattee Constructed Well Depth ft <br /> COMMENTS,% ��� , f <WV �J(Cd �W51^�-77-'11 IIIkELV IJCSN')y pr�1L— "/, <br /> PE Sc Received Check#1 Amount Permit! 7 <br /> Codes Info By <br /> Cash Remitted Date Service nest# Invoice# WelllD# <br /> EHD43-05 6!112019 'L 'NELLIPUMPPFAAIIT <br /> l�li� ID��I���� IIDIv�10�22 <br />