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I <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-0232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 62 7s1 Tha cr-)+L n r4 CITY/LP <br /> \- l D <br /> CROSSSTREET f-/'ctnc7c1 P APN �/�r S / y/ PARCEL SIZE LAND USE APPLICATION# O <br /> OWNER NAME c,l 1�I OT K1X'I PHONE <br /> OWNER ADDRESS ZZ (� /�(�_ � 'C_e. CITY/STATE/ZIP ,. Cjg 9,5, "t9/a <br /> CONTRACTOR F ouncl[]S PHONE <br /> —T -I—_ C <br /> CONTRACTOR ADDRESS lO I KEY>�L�C' �Jod P Cm/STATE/ZIPIAnCY4 lei cl l ca }s lO 9s- <br /> SUBCONTRACTOR/CONSULTANT PHONE 7� <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE X-57 C-61 D-09 Other NUMBER 1.301 M3 EXPIRATION DATE 7 311 -�O.ZO <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC,WELL SAMPLING: General Mineral/Colifonn Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> I Public Water System <br /> 8 dieerent from Owner Water System Name Contad Name or Phone Number <br /> TYPE OF WORK t New Well Replacement Well n Well Afleration/Modification C Other <br /> L Monitoring Well(s) #of wells ❑Soil Boring(s) a of eoD^tis r Geotechnical s or borings <br /> C Out-Of-Service Well Si Out-Of-Service Well Renewal CI Cross-Connection Repair <br /> New PUMP L Pump Replacement 7 Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method L Mud Rotary a Air Rotary Auger Cable Tool Push Point )(Other OUJ I i Conn 16,4e o <br /> Proposed Well Depth fl Excavation in diameter '....Open Bottom Gravel Pa�avel Size in diameter <br /> F Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth_ft Neat Cement(94/b bag15-10 gal water) Sand Cement sack mix!/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 it Length It Thick in ' Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level tt <br /> 1 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 UM 48 HOUR ADV CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209))9953--7697 <br /> SIGNED_ _ ;iii. TITLE DATE <br /> qP CF�VJD <br /> R <br /> ?? X44? <br /> RO //V COVN <br /> DFpq RTMEN�!' <br /> 77DEPARTMENT USE ONLY <br /> Application Accepted By �/– � Date ; Area / Employee ID# S K <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By rrrlL•9L,.0 L: 11i;12 �. L Dale 5�f 2`L iJ WAIVER Received <br /> Soil Bonn g Inspe)tion By //�� ^- Constructed Wall Depth k <br /> COMMENTS ?ti 1�111,4 f r-'Wi F r rr!CIF <br /> J <br /> J <br /> PE Sc Received Check#/ Amount Date Perms Invoice If Well IDN <br /> Codes Info Cash Remitte I Ica Re uest <br /> c <br /> as J <br /> EHO43-06 6111(2019 7/� WELL/PUMP PERMIT <br />