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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 "IJ0 CITY/ZIP sto'- -"1Vn 11'522u--� m <br /> CROSS STREET Qa.-' <br /> �1 APINTJl � _PARCEL SIZE 10'/)-pVgAND USE APPLICATIOONz# <br /> rn <br /> OWNER NAME 5U(k` ' J�I1P 'cf51 <br /> D <br /> PHONEJ(]�G��n U) <br /> OWNER ADDRESS �O` �Sy� QJ� )to(r- CITY/STATE/ZIP 5AO(,'-b� CA -IJZOZ <br /> CONTRACTORy & � Yl,, n-J PHONE (20cU) <br /> CONTRACTOR ADDRESS ,,; ) Votu'04117)(Al d WDM_ CITY/STATE/ZIP (�a1f1 (QCR <br /> SUBCONTRACTOR/CONSULTANT VV Q11UL7�'`—�jK�U�O` omo(�\CAW3 PHONE C` 1 J(~ t�/(] <br /> SUBCONTRACTOR/CONSULTANT ADDRESS vv�J J'na0 '&+r(ut b\r(A' CITY/STATE/ZIP �eJ� v�/r(k�0� `�``g5ll tI <br /> LICENSE q,C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 120`104 EXPIRATION DATE .Z0Z V <br /> BILLING PARTY: DOWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring A 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 1 Soil Boring(s) #of borings A Geotechnical 6 #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary A Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth I S`50 ft Excavation 0-'S 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 IS-So ft A Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method 11 Pumped i& Free Fall J5 Other �c2Trl�8 t� u,u%r e'❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By EI Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal[j Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI./MUMJ 48 HOUR ADVANCE NOTICE REQUIRED FOR <br /> cINSPECTIONS <br /> , -PLEASE CALL(209) 953-7697 <br /> SIGNED I""l/V / TITLE �J` ,1��C DATE <br /> i <br /> se,rh <br /> -RE 94 <br /> U <br /> E qVIRC NN ENTA <br /> i FDA LT <br /> 1 7— <br /> D ARTMENT USE O LY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By ,(} {— Date WAIVER Received <br /> Soil Boring Inspection By t X A uM Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount at Permit] Invoice# Well ID# <br /> Codes Info Cash Remitted 7 Service Re uest# <br /> EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />