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-,�l P �,, WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT wWW.B- oV.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> � � —_ J <br /> JOB ADDRESS b�� t � � CITYIZIyP_1 1G—j(,�L_ � <br /> T'r � m <br /> CROSS STREE "�G�.Q �\.%1�-- D{ZPpN �2D--i T{PARCEL SIZE LI_GLAND USEEJ APPLICATION# p <br /> OWNER NAME ; P , <br /> �J PHION'E <br /> 7--;7> <br /> OWNER ADDRESS --;77j'C�� JF) �i �.� CITY/STATE/ZI <br /> CONTRACTOR r v'7� (—/(\�j —F PHONE <br /> CONTRACTOR ADDRESS LC1t2` 1 'kms Lr�z�`�j�r„P ` CITY/STATE/ZIP (l�i� �s�T��42 62; _ <br /> S U BC ONT RACTOR/C 0 N SULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE y[1YC-57 n C-61 D-09 -1Other NUMBER 1 EXPIRATION DATE ' - L.� L� <br /> BILLING PAR/TY: ❑OWNER ❑CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:!.I General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)"-Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial U Water Quality Monitoring I Soil Sampling/Characterization <br /> If different from Owner: Water System Name Contact Nitme or Phone Number <br /> TYPE OF WORK New Well Replacement Well i I'Well Alteration/Modification 'Other 0 <br /> Monitoring Well(s) It of wells fl Soil Boring(s) a of borings - Se"Oe nSI a of bonngs <br /> Out-Of-Service Well L Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement C Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION �, P_ •�p�y� a� C/`_F ENT <br /> Drilling Method Mud Rotary Air Rotary }Auger U Cable Tool d Push Point El Other "f 1� I V�D <br /> Proposed Well Depth ,it it Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft H O ^O�O <br /> Well Casing Diameterin Thickness/Gauge/ASTM Sched�U i Steel -)(Plastic Stainless Steel Other L <br /> Grout Seal Depth ��S ft Neat Cement(94 Ib bag/5-10 gal wafer) _ Sand Cement sack mix g �) OQU//�CO NT <br /> Bentonite(20%solids) n Other <br /> Grout Placement Metho Pumped '! Free Fall Other Retardant/Accelerator(name) EPMENTAL y <br /> PEDESTAL Installed By Driller Pump Contractor Other ART MENT <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP SubmersibleTurbine Other HP Pump Set it 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> ,MINIMUM 49 HOUR Af !INCE NOTICE REQUIREf3 FOR INSPECTIONS-i`I_FASEE CALL(209)953-7697 <br /> SIGNED ! TITLE '� (L1v/` �J{—� 1 DATE La <br /> AM I I I <br /> DEPARTMENT USE 0NLY <br /> / 1 <br /> Application Accepted By r_ L— Date J' ZJ�"� Area r Employee ID# <br /> Grout Inspection By Date fl SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring In pection By Date ConstiIucted Well Depth ft <br /> COMMENTS 'VAU Pil L' "I lC"O ,Y 1 f 'i1/I"rl -y i <br /> PE SC Received Amount Permit/ <br /> Codes Info By,-, s Remitted Date Service Request# Invoice# Well ID# <br /> ;I�7 ie; S1 lV <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />