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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 /> JOB ADDRESS 1��7 �D� JR�►an ,¢� CITY/ZIP_1 ' D 9$220 m <br /> '� <br /> CROSS STREET�jL/,j' XC/ _ApN f/ [..7/I �j U� j 3 PARCEL SIZES O r ` LAND USE APPLICATION# O <br /> L <br /> m <br /> OWNER NAME 4n,-11� ��} _ PHONE 227 5 9&- VS,6 N <br /> OWNER ADDRESS �, )33T_�� /7 CITY/STATE/ZIP s�Ipw &'d <br /> CONTRACTOR _ A"- c�`/2(�Cs�JG� //JG '/PHONE Z,5x �7Z-�7f5-,?j-2 <br /> �' 7 <br /> CONTRACTOR ADDRESS_/�YJ ,mac/ I��jJ/�GI /��/ CITY/STATE/ZIP k/ 1��a- 1 1 5 �/� /S,?j— <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS_ CITY/STATE/ZIP <br /> LICENSE k(C-57 rJ C-61 I I D-09 1_1 Other NUMBER,� EXPIRATION DATE ZU <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) i 1 Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑ Domestic/PrivateIrrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring a Soil Sampling/Characterization <br /> EI Public Water Syste _ <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 EI Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> L1 Out-Of-Service Well ❑ Out-Of-Service Well Renewal EI Cross-Connection Repair <br /> ew Pump jKPumpReplacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRU ION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 11 Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel LI Plastic 0 Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94/b bag/5-90 gal water) ❑ Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method F] 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 LI Christy ftx ❑ Stove Pipe <br /> EU MP Submersible❑ Turbine ❑ Other HP—�— Pump Set ft Standing Water Level—/az ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAI' 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 /> MINIMU 4 OUR AN E NOTIJE REQUIRED FO,R/INSPECTION�S-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE G - f/.-L DATEAV 1Z <br /> —--- <br /> OL <br /> lip <br /> UlIq <br /> C <br /> rA 16 ATAp <br /> DEPARTMENT USE ONLY <br /> Application Accepted By � Date Z Area Employee ID# <br /> Grout Inspection By Date j PECIAL Well Permit <br /> Pump Inspection By ttr-,A- stA (pyr,.4L �inl7. Date S! t3�2C,2J WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS 71-11 <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info By Cash emitted Date Service Request# Invoice# Well ID# <br /> 3.2— WPa <br /> EHD 43-06 6/11/2019 /�/MVyT � � I l���„ V/�.� WELL/PUMP PERMIT <br />