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1 t <br /> �r WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENveRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZF.LTON AVENUE-STOCKTON CA 95205-6232(209)4683420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 54 o z <br /> CITYIZIP <br /> CROSS STREET pI�APN�����`V�U / PARCEL S. <br /> LAND USE APPLICATION o <br /> OWNER NAME --J /'-/ 1.Y O PHONE Ly / 1Q !? <br /> OWNER ADDRESS _5, _e CITY/STATEIZIP "� ? <br /> CONTRACTOR PHONE_�"v nn <br /> CONTRACTOR ADDRESS CITYISTATE/ZIP C. <br /> SUSCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANTADDRESS CIITYYIISTTATE//ZIP <br /> LICENSE C C-57 D-09 C Other.V / NUMBERk> G / EXPIRATION DATE /✓- �/ <br /> BILLING PARTY: OWNER C CONTRACTOR _SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAM NG: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)'-Arsenic(4393) <br /> INTENDED USE V6omesncfPnvate ❑Irrigabon/Agricultural Industrial L Water Quality Monitoring Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from 0— Water System Name Conla f N.—mr Ph—NnnOer <br /> TYPE OF WORK L7114eW Well E Replacement Well ❑Well Alteration/Modification 1 Other <br /> C Monitoring Well(s) A of wells ^_Soil Boring(s) a of b0rylgs :1 Geotechnical a of borings <br /> Out- -Service Well G Out-01-Service Well Renewal Cross-Connection Repair <br /> ew Pum _ Pump Replacement ❑Pump Repair =Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 7 Mud Rotary -Air Rotary 7 Auger Cable Tool Push Point Other <br /> Proposed Well Depth _ft Excavation in diameter C Open Bottom -Gravel Pack/Gravel Size in diameter <br /> ,-Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched _ G Steel =Plastic Stainless Steel I Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) =Sand Cement sack mixn gal water <br /> Bentonite(20%solids) Other _ <br /> Grout Placement Method Pumped - Free Fall C Other -Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ump Contracto :1 Other <br /> Concrete Pedestal-Dimensions:Width�ft Length ft Thickin C Christy Box C Stove Pipe <br /> �i>ytn ubmersible Turbine ❑Other HP Pump Set It Standing Water Level ti <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 REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS OMPENSATION WS. <br /> Ll N1 3' ,L I:ANCE NOTICE REQUIRED FO%INSPECTIONS-PLEASE CALL(209)./53.7 97 <br /> SIGNE TITLE ✓"� DATE v <br /> 19 za19 <br /> J <br /> !n/ <br /> l MNTUNry <br /> 44- ��TM�nlr <br /> PA TMENT U E N L Y <br /> Application Accepted By_�k/ / Dale Area Employee IDA <br /> Grout Inspection By Date ❑ PECIAL Well Permit <br /> Pump Inspection ByrpnLll�c (bit w_ �_ Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth K <br /> COMMENTS <br /> PE SC Received CheckV Amount PerrnW <br /> Cods Info B Cash emitted DateServiuR uestS lnvekeA Well]DO <br /> 5� \A111 <br /> �7 <br /> If I <br /> EH043-06 &11/2019 WELL IPU%IP PERMIT <br />