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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1068 EAST HAZEI.TON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDA13LE�P"ECRMIIT www.sjgov.org/ehd yyf EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ✓.7•7 MQ Ili Le f 12- CITVIZIP 1_I Vh 41 <br /> CROSS STREETba nk 23"A _APNrZSII-300 -21 PARCEL SIZE `O.✓/LAND USF.'APPLICATION# p <br /> OWNER NAME A BSO C�.��v%. YwJ'll�si �Y1.C• PHONE_YS/��/-SOO OQ 9 <br /> OWNER ADDRESS _� l �' �U-S`I� CITVISTA7EIZIP/n SIV <br /> -G- <br /> CONTRACTOR MAS{fh5PHONE <br /> CONTRACTOR ADDRESS Albt-4, CITYISTATE/ZIPJ► Sbk�6 /!/ <br /> q <br /> rf�S7 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS �CIIT/Y�IS'rATEIZIP I '/ <br /> LICENSE yQ C-57 D C-61 U D-09 Ll Other NUMBER IEft ExPIRATION DATE u,, " <br /> BILLING PARTY: IOWNER II CONTRACTOR I SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:!I General Mineral/Coliform Bacteria(4391)tI Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private D Irdgalion/AgricUllural D Industrial D Water Quality Monitoring D Soil Sampling/Characterization <br /> D Public Water System — <br /> If dlrferenl from Owner Water System Name Conlacl Neme or Phane Number <br /> TYPE OF WORK New Well D Replacement Well O Well Alteration/Modification D Other <br /> D Monitoring Well(s) #of wells D Soil Boring(s) H or borlogs D Geotechnical_ N or borings <br /> 1:1 Out-Of-Service Well D Out-Of-Service Well Renewal D Cross-Connection Repair <br /> D New Pump D Pump Replacement D Pump Repair D Raise Well Casin <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary D Air Rotary D Auger D Cable Tool D Push Point O Other <br /> i <br /> Proposed Well DepJ�b it Excavation !Z / in diameter FI Open Bottom 'K Gravel Pack/Gravel Size in diameter <br /> D Conductor Casing in diameter / Conductor Casing Depth fl <br /> Well Casing Diameter_�2_in Thickness/Gauge/ASTM Sched ZaO U Steel l)I(Plastic D Stainless Steel D Other <br /> Grout Seal Depth[¢V it D Neal Cement(94 lb bag/5-10 gal water) 0 Sand Cement sack mixl7 gal water <br /> Xkentonite(20%solids) D Other <br /> Grout Placement Method (Pumped D Free Fall D Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller Pump Contractor D Other <br /> ❑Concrete Pedestal 0Dimenslons:Width it Length ft Thick in O Christy Box D Stove Pipe <br /> PUMP D Submersible Ll Turbine D Other _ HP Pump Set It Standing Water Level It <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 /> MINI 4£f HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED­ _ TITLE DATE——---—---——————P - ——————————— <br /> ------------- <br /> ------------- <br /> --------------- <br /> ------------ <br /> --------------- <br /> G <br /> T <br /> -Ti Ao C <br /> r <br /> DEPARTMENT USE ONLY <br /> Application Accepted By_61I�I Vt/ 0 DaleLV Area Employee ID# <br /> Grout Inspection By Date !I SPECIAL Well Permit <br /> Pump Inspection By— Date_ _ I I WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth — ft <br /> COMMENTS <br /> PE SC Received Check Amount Date Permit/ Invoice# Well ID# <br /> Cod s Info Remitted Service Request# <br /> It —2 0 00 <br /> N I 3 ZD 0 03 05-Z? <br /> WELL/PUMP PERMIT <br /> END 43-06 GM112019 <br />