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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 CITY/ZIP m <br /> CROSS STREET AP ~ PARCEL SIZE LAND USE APPLICATION# D <br /> A <br /> a -�� <br /> OWNER NAME10/1 41N A <br /> PHONE <br /> c <br /> OWNER ADDRESS l(Jl/ k)gCITY/STATE/ZIP �nt�CS I�lYl <br /> CONTRACTOR PHONE ao?�//�'� l-/3d_`10 <br /> CONTRACTOR ADDRESSAAW LJ—r <br /> CITY/STATE/ZIPS bjd�v_ 'J6-0—Q/ 5- <br /> SUBCONTRACTOR/CONSULTANT PHO/NE�y-1, / �'j��►�ln� - 'L "{-7 <br /> SUBCONTRACTOR/CONSU <br /> XC-61 <br /> LT <br /> ANT ADDRESS CITY/STATE/ZIP <br /> LICENSE KC-57 ❑ D-09 ❑ Other NUMBERAZI& EXPIRATION DATE U-N-2/ <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural n 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 r: Geotechnical #of borings <br /> ❑ Out-Of-Service Well Ci Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump 11 Pump Replacement 11 Pump Repair LiRaise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 6Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom r. Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> r <br /> Well Casing Diameter_ ?_ in Thickness/Gauge/ASTM Sched 900) = Steel X Plastic ❑ Stainless Steel a Other <br /> Grout Seal Depth 100 ft Fi Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> 'A Bentonite(20%solids) ❑ Other <br /> Grout Placement Method&Pumped ❑ Free Fall ❑ Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller A Pump Contractor _ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length T ft Thick in il Christy Box a Stove Pipe <br /> PUMP Submersible❑ Turbine Other HP Pump Set Oo ft Standing Water Level /S-O t 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 /> MINI V 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTI S -PLEASE CALL(209)953-X776977 � <br /> SIGNED / TITLE DATE <br /> ev cU <br /> D pA <br /> RIA Wt <br /> 177 T <br /> E ARTMENT U E ONLY <br /> Application Accepted By Da If Areae Employee ID#� <br /> Grout Inspection By p Date ZI IC2,1 SPECIAL Well Permit <br /> Pump Inspection By Date �0 4Z 11'7 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received heckAmount Date Permit/ Invoice# Well ID# <br /> C d s I r1fo B V A Cash Remitted Service Request# <br /> IV 44 <br /> q <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />