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WELL/PUMP PERMIT <br /> s SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZEI TON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT Q nwww.sjgov.org/ehd EXPIRES 1�YEAR FROMDATEISSUED <br /> JOB ADDRESS 1 3341 Je Y�•C f IL CITY/LPC Z 7S J ZO y <br /> Fsca 1e1tiT � <br /> v�f� �f q e D <br /> CROSS STREET H(wy r2•0 T y APN GILq`1S V'GIGO PARCEL SIZEI-1310•1710 LAND USF.APPLICATION#�T 0 <br /> OWNER NAME I�tf-hAr� J U`r PHONE fya- Two �! <br /> OWNER ADDRESS IS33 \ Se;(1V%tr• "• CITYISTATEIZIP :W4C4Ltlr / Cel 45326 <br /> CONTRACTOR NI QS hC-• PHONE_-222 <br /> J t q 2 v <br /> CONTRACTOR ADDRESS il A l he f-S I_�",e-��- CITYISTATEIZJP M ades*y- C-1CY f gs7 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATEIZIP <br /> LICENSE )QC-57 CI C-61 LI D-09 D Other NUMBER - ExPiRAnGt9DATE 41 30 LTi <br /> BILLING PARTY: rI OWNER CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WESL SAMPLING:'I General Mineral/Coliform Bacteria(4391)!-Dibromochloropropane(4392);!Arsenic(4393) /A�-- <br /> INTENDED USE Domestic/Private 0 irrigation/Agricultural D Industrial 0 Water Quality Monitoring 0 Sol]Sampling/Charecteriza <br /> 0 Public Water Systemor <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK XNewWell 0 Replacement Well 0 Well Alterallon/Modificalion 0 Other ✓,(1!,tY�_ <br /> U Moni(oring Weil(s) #of wells 13 Soil Boring(s) 0 of borings 0 Geotechnical #°f t""h 20 <br /> 0 put-Of-Service Well n Out-Of-Service Well Renewal 0 Cross-Connection Repair �� o U � U�p <br /> 0 New Pum 0 Pum 0 Replacement Pum Re alr 0 Raise Well CasingV� <br /> WELL CONSTRUCTION q/jT <br /> Drilling Method yMud Rotary O AIr Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other MFNr <br /> Proposed Well Depth_„ 0 R Excavation )Z" in diameter fl Open Bottom dt Gravel Pack/Gravel Size # In diameter <br /> 0 Conduct r Casing In diameter / Conductor Casing Depth fl <br /> Well Casing Diameter In Thickness/Gauge/ASTM Sched 7-040 U Stael Plastic rI Stainless Steel 0 Other <br /> Grout Seat Depth 2,00 it 0 Neat Cement(94 Ib bag/5-f0 gal water) 0 Sand Cement sack mlxl7 gal water <br /> ,kBentonite(20%solids) U Other <br /> Grout Placement Method O&Pumped 0§fee Fall U Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By U Driller 4Pump Contractor 0 Other <br /> 0 Concrete Pedestal ODimenslons:Width fl Length ft Thick In 0 Christy Box 0 Stove Pipe <br /> PUMP 0 Submersible Turbine U Other HP Pump Sel ft Standing Water Level ft <br /> 1 HEREBY CERTIFY THAT 1,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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED_ TITLE CO%— DATEOL <br /> 1 <br /> ' C <br /> t <br /> "6 <br /> Y <br /> /1 DEPARTMENT./USE ONLY <br /> Application Accepted By 1. Dale 1LZlT Area Employee ID# Q <br /> Grout Inspection By Date "TT ;.I SPECIAL WQII Permit <br /> Pump Inspection By Date 'I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS C(jj4:VAAy In&,,L- ,4Q IAJ IU <br /> PE SC Received Che Amount Date Permit/ Invoice# Well ID# <br /> Codes Info BV1 ash Remitted Service Request# <br /> 4,290-0 '01-101.402 <br /> EHD43-06 N1112019 WELL/PUMP PERMIT <br />