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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTA.EALTH 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 ��((�, ,t <br /> CROSS STREET a—\G��p.yr� �il�. ./gpN rZ` �Cl\PARCEL SIZE-'/Q'rl/LAND USE APPLICATION# v <br /> OWNER NAMEGIT l U�J {PJHONEZ '�>! <br /> � <br /> OWNER ADDRESS -;7? 2 I t;2; CITY/STATE/ZlrE T�_q <br /> i _ <br /> CONTRACTOR �F/`7ti l f��_j�/(��j' -L F PHONE :,{:f A —�—�,� ' <br /> CONTRACTOR ADDRESS' /�~'���' A_A <br /> CITY/STATE/ZIP /f i" <br /> SUBCONTRACTOR/CONSULTANT._ ._ �—* � PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP // <br /> LICENSE XC-57 I C-61 D-09 -1 OtherNUMBER�� EXPIRATION DATE C/ L <br /> BILLING PARTY: ❑OWNER ❑CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:i I General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)"" Arsenic(4393) <br /> INTENDED USE Domestic/Private - Irrigation/Agricultural Industrial ❑Water <br /> Quality Monitoring I Soil Sampling/Characterization <br /> l <br /> If dlHerent from owner: + Water System Name Contact NEtme or Phone Number <br /> TYPE OF WORK New Well L'.Replacement Well i I Well Alteration/Modification Other J Gj <br /> Monitoring Well(s) #of wells n Soil Boring(s) #of boringseo ec NAI #of borings <br /> Out-Of-Service Well L Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum -i Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION ` / �; �. !i., <br /> Drilling Method Mud Rotary Air Rotary Auger Ll Cable Tool Push Point F D Daher <br /> Proposed Well Depth It Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter p <br /> Conductor Casing in diameter / Conductor Casing Depth It Y <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic - Stainless Steel Other REQ M�NT <br /> Grout Seal Depth ,?j ft Neat Cement(94/b bag/5-10 gal water) _ Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) I-I Other A <br /> Grout Placement Metho Pumped I Free Fall Other Retardant/Accelerator(name) A)DpO2 <br /> PEDESTAL Installed By : Driller Pump Contractor Other 02 <br /> Concrete Pedestal :Dimensions:Width ft Length It Thick in Christy Box Stove Pipe ^/)/Oq o <br /> PUMP Submersible Turbine Other HP Pump Set It Standing Water Level fl TH p�grC/C�L�T Y <br /> IHEREBY CERTIFY THAT I HAVE PREPARED <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS HANDPRULESTA D ( OND <br /> ANDREGULATIONS-ND THAT THE NIA SO CERTIFYACCORDANCE <br /> LICENSE WITH IS RTNjENT <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> OINIMUM 48 HOUR.- ,,ICE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)95^>-7'9( <br /> SIGNED TITLE (L/�� � DATE - ' <br /> /- DEPARTMENT USE ONLYA't`�T 1 'U <br /> Application Accepted By 7 Z Date '�` 20L Area '-' C/ Employee ID# <br /> Grout Inspection By Date A f: SPECIAL Well Permit <br /> Pump Inspection By Date f WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth tt <br /> COMMENTS C jj,,ftAk <br /> I n1' + 111 /t.7 d�P 9���4a 4t, J <br /> °��:r9r �2 CtL �l�--s-e 121 11 -yl1. <br /> PE Sc Recelved kQttcW Amount Date Permit/ invoice# Well ID# <br /> Codes Info B Cash Remltted Service Request# <br /> 4 <br /> EHD 43-06 6111/2019 WELL/PUMP PERMIT <br />