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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 /> JOB ADDRESS 6 CITY/ZIP/" tO� -? �T� <br /> I 'w T a <br /> CROSS STREET NLrIG APN 7-1 L- 346'190 PARCEL SIZE 0•qW LAND USE APPLICATION III- A <br /> ,• 3ZL <br /> OWNER NAME 1�\�R.� `xaY7�'� PHONE679 3 v! <br /> OWNER ADDRESS - <br /> T`K' CITYISTATE/ZIP '•QN.T r�LrAr.� (1 9 VjW <br /> CONTRACTOR ►_' \Q.G'wC`�.T1�1 1-b,y"A.1of `J1 • PHONEdLLQ 1 V-0 . <br /> CONTRACTOR ADDRESS 1 1 /� 1 YJC rS it;( CITY/STATE/ZIP .G(lri4. �A�s;✓7 <br /> SUBCONTRACTOR/CONSULTANT _ PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATEIZIP <br /> LICENSE )(t-57 0 C-61 U D-09 Ll Othef NUMBER""AZZ, EXPIRATION DATE <br /> BILLING PARTY: IOWNER 14,10tONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:I I General Mineral/Coliform Bacteria(4391)I I Dibromochloropropane(4392)1:Arsenic(4393) <br /> INTENDED USE Domestic/Private D Irrigallon/Agricultural r.1 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If dirtereN from Owner. Water System Name Contact Name or Plime Number <br /> TYPE OF WORKNew Weil 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> 0 Monitoring Well(s) #of wells 0 Soil Boring(s) for Iw TIAs 0 Geotechnical a or°°TIAs <br /> 13 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method'yMud Rotary 0 Air Rotary 0 Auger D Cable Tool. 0 Push Point 0 Other <br /> Proposed Well Depth 180 fl Excavation it 0 In diameter D Open Bottom Gravel Pack/Gravel Size in diameter <br /> 0 Conduct}`Casing In diameter / Conductor Casing Depth ft <br /> Well Casing Diameter'I in Thickness/Gauge/ASTM Sched 2-A70 0 Steel )Plaslic n Stainless Steel 0 Other <br /> Grout I Depth /QO ft D Neat Cement(94 Ib bag/5.10 gal water) 0 Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) D Other <br /> Grout Placement Metho umped 0 Free Fall U Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 11 Driller 0 Pump Contractor El Other <br /> 0 Concrete Pedestal❑Dimensions:Width 0 Length It Thick In 0 Christy Box D Stove Pipe <br /> PUMP 0 Submersible Turbine 0 Other HP Pump Set If Standing Water Level If <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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MI 1W4B HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)1953-7697 <br /> SIGNED DATE `/'7—_ <br /> lip1 <br /> LH <br /> V Lji--- ----- T <br /> / N <br /> T <br /> fl ±�— 9 1 -1 1 1 <br /> N <br /> PA TM ENT U E NLY <br /> t <br /> Application Accepted By Dale ?� Area Employee ID#� <br /> Grout Inspection By Date PECIAL Well Permit <br /> Pump Inspection By Date i WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth ft <br /> COMMENTS <br /> PE SC ReceivedChock Amount Date Permitl Invoice# Well ID# <br /> QodeS Info B Remitted Service Request# <br /> •(2.20 <br /> 0 o as <br /> 2 (2 2V1W 0D 4rv1 16 <br /> WELL(PUMP PERMIT <br /> EHD43.06 611112018 <br />