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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 www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> �MS AyQ'V ✓"`� _ CITY/ZIP �I / m <br /> CROSS STREET T �/7 ILA-IS <br /> f APN �J�"� �F+(11U2<PARCEL SIZE�jV LAND USE AAP�P�LIICATI/OWN#� <br /> OWNER NAME [ AIy1I,10 W�g � �/ PHONE(z it Qi(!!JZ <br /> OWNER ADDRESS / U i �� CITY/STATE/ZIP )24V Aj <br /> CONTRACTOR t5kA ! PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE _ C-57 C-61 D-09 _ Other NUMBER EXPIRATION DATE <br /> BILLING PARTY: _OWNER _CONTRACTOR _ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> Ot <br /> INTENDED USE Domestic/Private _. Irrigation/Agricultural 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 Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells _ Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCT <br /> Drilling Method _ Mud Rotary _ Air Rotary _ Auger Cable Tool Push Point _ Other <br /> Proposed Well Depth ft Excavation in diameter ._ 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 Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method _ Pumped _ Free Fall Other _ Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal _Dimensions:Width ft Length ft Thick in _ Christy Box _ Stove Pipe <br /> PUMP Submersible Turbine _ Other HP__7— Pump Set t� 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 /> INI M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(2,099) 953-7697 / <br /> SIGNED TITLE X CW 4'Q1 DATq� <br /> IPJ Nb E <br /> UP Ty <br /> IIEDALTI I D ME Nl� <br /> EP RTMENT USE NLY <br /> t <br /> Application Accepted By Date y q Area4da/f Employee ID# <br /> Grout Inspection By Date 1 PECIAL Well Permit <br /> Pump Inspection By �C4v.�ii+ GF (�.�. Date 21 al 11A,1-0 I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount to Permit/ Invoice# Well ID# <br /> Q0_4@§. 1 Cash Remitted Service Request# <br /> v <br /> W P 0 0 404x0 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />