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h•4 <br /> 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.org1ehd EXPIRES 1 YEAR FROM DATE ISSUED LA <br /> 2SS31 A�{�r CITY/ZIP 1„I RS3L,� m <br /> JOB ADDRESS LL ary +� �y 2 5* <br /> AND STREETtd 0.` 6J3I�_�.----_ APN ZS1-300 _2 PARCEL SIZE , J /LAND USE APPLICATION# <br /> I Ise-- } ' 4 --- 4 8t{-SOD o <br /> OWNER NAME C �6 A«-� 1 N � A./�yJrl y►.0. nnn PHONE_ <br /> OWNER ADDRESS `- RIu�T�H __ _ _ CITY/STATE/ZIP�V Ir\ <br /> CONTRACTOR Mas{11 IS pry 1`1-,4, ZF-rt• _ _ PHONElS2Z- {`J <br /> CONTRACTOR ADDRESS 16tns tZd t CITY/STATE/ZIP fso; ( "/ rS.7✓ J <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS _ CITY/STATE//ZIP <br /> LICENSE �<C-57 ❑ C-61 ii D-09 11Other NUMBER luk-W Z EXPIRATION DATE_`t <br /> BILLING PARTY: i OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING::i General Mineral/Coliform Bacteria(4391)! Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private ll Irrigation/Agricultural ❑ Industrial 11 Water Quality Monitoring ❑ 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 1.1 Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> 1-1 New Pump ❑ Pump Replacement ❑ Purnp Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ri Other <br /> Irl <br /> Proposed Well Dep 96 ft Excavation ►Z in diameter ❑ Open Bottom `ir Gravel Pack/Gravel Size 6 in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter�2— in Thickness/Gauge/ASTM Sched Zia ❑ Steel Wlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth"V ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> bentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersibleo 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 953-7697 <br /> SIGNED_- ----------- _ TITLE �lL`�KC _- -- DATE Z-Zd <br /> GPAL <br /> AAAAi <br /> r <br /> �r oUhzhc <br /> r <br /> DEPARTMENT USE �Os�NLY <br /> 3 ?D20 Area Employee ID# <br /> Application Accepted By Date ''!!1� <br /> Grout Inspection By Date 707�J SPECIAL Well Permit <br /> Pump Inspection By Date 1 1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS k <br /> PE Sc Received Check Amount Date Permit/ Invoice# Well ID# <br /> Codip? Info Remitted Service Request# <br /> 1 \,-)(-)01D <br /> ►k l I 3 2 IaPDDN Oso <br /> 30 3 W O� 05 S <br /> EHD 43-06 6/11/2019 WELL(PUMP PERMIT <br />