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WELL/PUMP PERMIT <br /> :•AN 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 /> ��6���� to <br /> JOB ADDRESS ,� _ CITY/ZIP///�tdK. Q T3 --- m <br /> f w �— — m <br /> CROSS STREET—/ APN 2�L���' �Ld PARCEL SIZE 0A6 LAND USE APPLICATION#__ _ o <br /> m <br /> 671? ? m <br /> OWNER NAME _M t Ick _ 1(Ord' PHON(. r ✓ 2 _ _ N <br /> OWNER ADDRESS 10086 f,.%S I j1:5 v- CITY/STATE/ZIP M'9.t e L Aa Ot- 95?3-,6 <br /> CONTRACTOR , ' \a.S a ��) r 1 1 1,1� • _- _ PHONE r t <br /> CONTRACTOR ADDRESS L1 1 A �be�s _ CITY/STATE/ZIP�VI���rA gyI'+✓I <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE XC-57 i1 C-61 �/i D-09 i j Other NUMBER�— EXPIRATION DATE 'f 40_-JL. <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 P Irrigation/Agricultural H Industrial ri Water Quality Monitoring P Soil Sampling/Characterization <br /> I Public Water System_ <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORKNew Well n Replacement Well 1.1 Well Alteration/Modification 11Other <br /> XP Monitoring Well(s) #of wells I I Soil Boring(s) #of borings ❑ Geotechnical #or borings <br /> !I Out-Of-Service Well I I Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> 1--1 New Pump i] Pump Replacement 11 Pump Repair rl Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method'*yMud Rotary P Air Rotary 1 Auger U Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 80 ft Excavation )a AP in diameter 9 Open BottomGravel Pack/Gravel Size o in diameter <br /> ar r ConductQrr Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter w in Thickness/Gauge/ASTM Sched �t70 -1 Steel Plastic; i i Stainless Steel C Other <br /> Grout Sea epth��� fl I-] Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> Bentonite(2.0%solids) P Other <br /> Grout Placement Methoal-Icumped U Free Fall rl Other ❑ Retardant/Accelerator(name) <br /> PEDFSTAL Installed By ❑ Driller ❑ Pump Contractor H Other <br /> Cl Concrete Pedestal❑Dimensions:Width_ ft Length _ ft Thick — in 11 Christy Box ❑ Stove Pipe <br /> PUMP ii Submersible❑ Turbine ❑ Other _ HP Pump Set _ft Standing Water Level ft <br /> I 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 /> MI 4AW HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209)953-7697 <br /> SIGNED -- IT �d 'Q DATE <br /> lw- <br /> S <br /> h T <br /> N <br /> PA TMENT U E NL.Y <br /> c <br /> Application Accepted By Date y��� Area Employee ID# <br /> Grout Inspection By Date PECIAL Well Permit <br /> Pump Inspection By Dale WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check Amount Permit/ode Info B mitted Date Service Re uest# Invoice# Well ID# <br /> S •12.20 N <br /> zb 2.12• <br /> 10 0 0 asl <br /> 2•(2.2 0� 051 <br /> EHD 43-06 6111/2019 WELL/PUMP PERMIT <br />