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WELL/PUMP PERMIT <br /> t SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> -11017 <br /> Joe ADDRESS -5- l.r - OY'$' r/�",+ CITYIZIP/'/✓r,�/1 y�._ � m <br /> /� D <br /> CROSS STREET • APYNnl� w PARCEL SIZE 7-.1 LAND USE APPLICATION# y <br /> "73 111 <br /> OWNER NAME ! l I Ze-LI`/.� I / HONE�D s/�- <br /> L �J— <br /> S� O <br /> OWNER ADDRESS �,' CITYISTA c �1 S33G� <br /> &� Q <br /> CONTRACTOR N O."A S I <br /> _ l _ _ PHONE I <br /> CONTRACTOR ADDRESS TpG Oi' 4/9"/STATEIZIPrl C — c/��Jt <br /> SUBCONTRACTOR <br /> PHONE _ <br /> SUBCONTRACTOR ADDRESS �J CITYISTATEIZIP / 7. <br /> LICENSE C-57 -61 0-09 Other <br /> ✓) NUMBER EXPIRATION DATE <br /> DOMESTIC WELLSAMPUNG:-General Mineral/Coliform Bactena(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE omesticlPnvate _ IrngatioNAgncultural - Industrial <br /> -Water Quality Meni oring .,Soil Sampling/Characterization <br /> -Public Water System <br /> It rli@erenl hom Owner Wale,System Name Contact Name w Phone Number <br /> TYPl OF WORK Q New Well -Replacement Well ❑Well Alteration/Modification - Other <br /> Monitoring Well(s) #of wells -Soil Boring(s) v' =Geotechnical <br /> G Out-Of-ServiceWeill -Out-Ot-Sernce Well Renewal Cross-Connection Repair <br /> New Pum !Pum Replacement =Pump Repair -Raise Well Casin <br /> WELL CONSTRUCTION <br /> Drilling Method _Mud Rotary Air Rotary -Auger - Cable Tool Push Point Other <br /> Proposed Well Depth R Excavation in diameter -Open Bottom -Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth fl <br /> Well Casing Diameter_in Thickness/GaugefASTM Sched -Steel :_Plastic -Stainless Steel Other <br /> Grout Seal Depth ft - Neat Cement(941b bag/5-10 gal water) -" Sand Cement sack mtxf7 gal water <br /> -Bentonite(20%solids) _ Other <br /> Grout Placement Method _:Pumped _Free Fall -'Other =Retardant I Accelerator(name) <br /> PEDEsrAL Installed By _ Dnller Pump Contractor - Other <br /> Concrete Pedestal_Dimensions.Width It Length tt Thick in -Christy Boz _Stove Pipe <br /> UMP Submersible_Turbine -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 /> INIMUM 48-HOUR ADVANCE NOTICE REQUIRED FOR INSPECTION -PLEASE CALL(209)953-7697 <br /> SIGNED �l� Tm r-/.:N 1 r"Z-W DATE i Z-Ze _I CI <br /> PA <br /> 7- <br /> _ A�Jq� <br /> a� 2020 <br /> �gQUI <br /> AI tCTjy�pMENT-Nry <br /> pRTMENT <br /> A rMENT PSEVONLY <br /> 1 -_� <br /> Application Accepted By Date (N Area Employee ID# <br /> Grout Inspection By Date_. - SPECIAL Well Permit <br /> Pump Inspection By <br /> __9C�r 17K r'k' Date 2i - y(, _ WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check## Amount Permit/ Invoice# Well ID# <br /> Codes Inco Cas emitted ate Service Re uest# <br /> WELL/PUMP PERMIT <br /> EH043.06 r4 4/I4l18 <br />