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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 W-WW.S v.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS +�1 Q �} CITY/ZIP G Q cJ 4-2"O m <br /> CROSS STREETZ( (2y7--15(y' ,{ D <br /> jA�PN (1' PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME Coo.t"'1 i �\ d [ -:e (/Z' 1 1 / ��-� PHONE Z� I` 'y- b74 l <br /> OWNER ADDRESS • 0` -)R,<< ,Lf 0 CITY/STATE/ZIP A CrAn�C 0 �g�j'757-2 <br /> CONTRACTOR Tkk-'r'A!,. '1 �.0/'—,N\ �r 1N\N PHONE V 3Q— / 53 5a2J <br /> CONTRACTOR ADDRESS f© 17J�C cO 1 V CITY/STATEIZIP Qc�'oil <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTR`ACTORICONSULTANT ADDRESS CITY/STATE/ZIP rx, <br /> LICENSE V C-57 -C-61 ---D-09 - Other NUMBERA)117K EXPIRATION DATE 01 -3 207J� <br /> BILLING PARTY: OWNER __CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:i I General Mineral/Coliform Bacteria(4391)-Dibromochloropropane(4392)'-]Arsenic(4393) <br /> INTENDED USE 7.Domestic/Privat4'A Irrigation/Agricultural ❑Industrial I-Water Quality Monitoring -Soil Sampling/Characterization <br /> -1 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well i Replacement Well Well Alteration/Modification i-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 Pum 5 Pump Replacement -Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary ❑Auger 11 Cable Tool Push Point Other <br /> Proposed Well Depth6�ft , ixcavationin diameter "*v,Open Bottom i Gravel Pack/Gravel Size in diameter <br /> Condu rasing Z- in diameter / Conductor Casin Depth�ft <br /> Well Casing DiameteX in Thickness/Gauge/ASTM Schad•2-S<P 9`Steel Plastic -Stainles/teal Other <br /> Grout Seal Depth�_ft -Neat Cement(94 Ib bag/5-10 gal water) �jsand Cement /�-3 sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement MethodoF Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By El Driller -Pump Contractor Other <br /> i Concrete Pedestal r:;Dlmensions:Width ft Length ft Thick in ❑Christy Box �]Stove Pipe <br /> PUMP -Submersible-Turbine I-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 /> /`-Ii M 48 HOUR <br /> AD E NOTICE REQUIRED FOR <br /> INSPECTIONS <br /> -PLEASE CALL(209)953-7697 <br /> SIGNED � 21N TITLE `,` yKl Y1 A.` DATE <br /> YMENT <br /> CEIVED <br /> 0 4 2019 <br /> J DAQUIN COUNTY <br /> N/IRON MENTAL <br /> FIE E H DEPARTMENT <br /> ART ENT US O LY <br /> Application Accepted By Area ` Employee ID#_6f'//,y` <br /> Grout Inspection By Data 1 SPECIAL Well Permit <br /> Pump Inspection By f4o Date WAIVER Received <br /> Soil Boring Ins action By Date Constructed Well Depth bS ft <br /> COMMENTS T'i F S�,AL Q 1 01-, ht_ uvr �µ{LIT V:o,t'.i <br /> ,J84 7. (n N Lxf- sii� E-941AA �( rte .Su$fl 4-AU- <br /> PE SC Received Check#1 Amount Date Permit/ Invoice# Well ID# <br /> Codes Info A By Cash Remitted Service Re uest# <br /> 10 O I <br /> EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />