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1�Z� t--/(.'C S 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 /> A , <br /> JOB ADDRESS ��` (. (�, L�'� CITY/ZIP <br /> CROSS STREET,Z"�G•�iy�'�-I,L%j�- pl�Ppry —['�PARCEL SIZE LAND USE <br /> AAPPLICATIIOON7# p <br /> OWNER NAME PH`ON'E11— <br /> OWNER ADDRESS L-���C�< 1''7'x" `-� `(•�- CITY/STATE/ZIFT � <br /> CONTRACTOR , _111 I —N`�r� ( ✓(7k 6j IF Z_r PHONEf-f f <br /> CONTRACTOR ADDRESS�` \CJ` 1 '�C��/ ,( t-7 <br /> �- y�J`r-1r � CITY/STATE/ZIP__�_� <br /> SUBCONTRACTOR/C ONSULTANT 4 (fit PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS � CITY/STATE/ZIP <br /> i <br /> LICENSE y'.C-57 Il C-61 1-I D-09 -1 Other NUM13ER��' EXPIRATION DATE ! _ Li '2 <br /> BILLING PAR/TY\: D OWNER ❑CONTRACTOR -. SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING!❑General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial D Water Quality Monitoring -Soil Sam <br /> pli <br /> ng/Characterization <br /> If different from Owner: Water System Name ConIe t N o or Phone Number <br /> TYPE OF WORK New Well Replacement Well r1 Well Alteration/ModificationOther <br /> MonitoringWells #of wells 11 Soil Boring(s)s #of bodngs #of borings <br /> O 9O eo ec ni I <br /> Out-Of-Service Well L Out-Of-Service Well Renewal I I Crass-Connection Repair (�AY/I A^ <br /> New Pum2 Pump Replacement D Pump Repair SI Raise Well CasingRC ry <br /> WELL CONSTRUCTION / ^ `- /�.,Q ip� `CC'/�cVNt <br /> �DDrilling Method Mud Rotary Air Rotary ) Auger ❑Cable Tool Push Point Other C APR <br /> Proposed Well Depth S J ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft O2 �O <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched � Steel Plastic Stainless Steel Other S Jo 20 <br /> Grout Seal Depth J ft Neat Cement(94/b bag/5-10 gal water) _ Sand Cement sack mix/7 gal w 1,/Rd jV cotjNT y <br /> Bentonite(20%solids) 1 1 Other N DCPART�C <br /> Grout Placement Metho Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor I Other <br /> Concrete Pedestal Dimensions:Width it Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set it Standing Water Level ft <br /> , 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 LAW <br /> "48 HOL IR . <br /> , <br /> ANC NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(2099))953s--7697/ <br /> SIGNED �� TITLE T Zl( t/ � DATE ? <br /> /' DEPARTMENT USE ONLY"t`_'T <br /> Application Accepted By "'� DateJZ ZoZj Area '' Employee ID# <br /> Grout Inspection By Date I SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date w 7G� Const^ #-A!Drell Depth ft 1 <br /> COMMENTS .:t)14,2C4 [ h 1^1,cureY n <; r w_M)B L W irl� <br /> PE Sc Received Check Amount Date Permit/ Invoice# Well ID# <br /> Codes Info ash Remitted Service Request# <br /> EHD 40-06 6/11/2019 WELL 1PUMP PERMIT <br />