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WELLIPUMP 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 /> Ln <br /> JOB ADDRESS { CITY/ZIP � / <br /> '? <br /> 3 m <br /> CROSS STREET61,4C olyf f tf Gl ©©p PARCEL SIZE LAND US/Ep�APPLICATION# L� �J p^7 0 <br /> rn <br /> OWNER NAME <br /> /G 7�'"' ®1 _ PHONE!/'`V 3,0!^G �(/ / <br /> OWNER ADDRESS �_ � CITY/STATE/ZIP <br /> CONTRACTOR ����7P�7v cg l/—/` PHONE01 <br /> CONTRACTOR ADDRESS ! ��� CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS ^— CITY/STATE/ZIP *---- <br /> LICENSE )61---57 /l -61 EI D-09 ❑ Other NUMBER EXPIRATION DATE <br /> BILLING PARTY: D OWNER U CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: CI General Mineral/Coliform Bacteria(4391) ❑ Dibromochloropropane(4392)❑ Arsenic(4393) <br /> INTENDED USE omestic/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 Pum ump Replacement 0 Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <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 bagl5-10 gal water) ❑ Sand Cemeni sack mix17 gal water <br /> D 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 /> ry <br /> PUMP ubmersible❑ 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 /> �����IRED <br /> FOR INSPECTIONS -PLEASE CALL(209) 953.769,71 <br /> SIGNED TITLE �IG�%�` DATE f 2� <br /> c� <br /> Pv <br /> —1 Twq <br /> T <br /> � D <br /> 0 <br /> J q <br /> R N TY <br /> le, NT <br /> 74 �17 <br /> EP RTM ENT U WZ NLY 1 <br /> Application Accepted By Date � Area Employee ID#� � <br /> Grout Inspection By Date CI SPECIAL Well Permit <br /> Pump Inspection By f-r4rR,; S ht) bwti- #,I Date 31Z Igo-to L I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received heck Amount Permit/ <br /> Codes Info B Cash Remitte Date Service Request# Invoice# Well ID# <br /> I(�a0 iq <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />