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1 � <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENYIRDNMENTAL HEALTH DErArtril 1868 EAST HACI:LToN AveNue-STOCKTON CA 85205-6202(208)468-3420 <br /> NON-REFUNDABLE PERMIT art www.51gov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe Aool .30-403 S. I'IGC rhnur L)r)Ve, Cm21P —Ir.CQ 5377 <br /> y GROSS STREET W. LI-111 I(ODL APN ✓" L�) / PARCEL SIZE- LAND E APPLICATION# <br /> ■ OWNER NAME 1 r'aC M41erl&( Rccaver PNO.E(209)532-2355 <br /> f OWNERADDRESS 30`f0 S. I n.`aOrth­ OrlvL _ _- Cm/STATE/ZIP y%9g5�3/���1p�r� <br /> CONTRACTOR pT/G�/k//�)R ss`oc�o}esu ZYI(,. PLNONE��tIO !) r7U7 n`70VQ`�f/p Q <br /> CONTRACTOR ADDRESS 600!Ildr/!/1 AVC, 5 U(fe ZOU CrTYISTATEIZIP I�Gf1,7 CY-1rPcYk�C^ Z lT7 ZC1 <br /> SUBCONTRACTOIRICONSULTANT 1 QQ'C�j rO r l"rt;� S VI)C "PHONE <br /> SUOCOtITMCTQ,VCCN3ULTANTADDRC841(3)7 dde, CN e �r v rsTATe21r /C4�c�b �Or'dOytC.�CR�9��y <br /> LICENSE xC-51 C-til - 0-09 -- Other NUMBER (0 15 1 EXPIRATION DATE OC fr'bC' 31,20 <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOWCONSULTANT <br /> DomFSTIC WELL SAMPuNG: General MinerallColiform Bacteria(4391) Dlbromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE DomesuuPrivate ImgationlAgricultural Industrial _ Water Quality Monitoring Soil Sampling/Charactenzallon <br /> Public WaterSystem <br /> If different from Owner Water System Name Contact Nana or Phone Number <br /> TYPE OF WORK Nev,Well - Replacement Well -Well AlteraUon,?Aodificahon Other <br /> Monitoring Weit(s) _#otwers Sod Boring(s) "p1_"P XGeotechnical �-_-"o10OAiga <br /> _ Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum Pump Replacement Pump Repair Raise Well Cason <br /> WELL CONSTRUCTION <br /> Drilling Method _ Mud Rotary Air Rotary "XAuger Cable Tool Push Pont Other <br /> Proposed Well Depth 50 ft Excavation ly in.in diameter _ Open Bottom Gravel PackiGravei Size In diameter <br /> _ Conductor Casing in diametor r Conductor Casing Depth Jl <br /> Well Casing Diameter_in Thickness'GaugelASTM Schad - Steel -Plastic - Staniess Steel - Other <br /> Grout Seat Depth ft XNeat Cement(94 to bag/5.10 gal water) Sand Cement_ sacii mix17 gal water <br /> _Bentonite(20%solids i - Other <br /> Grout Placement Method Pumped Free Fail XOrher I f f M i e Retardant I Accelerator(name' <br /> PEDESTAL Installed By �XOflller - Pump Contractor Other <br /> ._ Concrete Pedestal Dimensions 'Width it Length h Thick in _Christy Box - Stove Pipe <br /> PUMP C Submersible Turbme - Other HP Pump Set ft 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 /> MINIMUM 48 Hl ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697/ <br /> SIGNED /; TITLE_ �/0tC�� �4lniz� DATE �l2¢l ZDV <br /> it <br /> RF yMFN <br /> Op <br /> CFS Lill 2020 <br /> .'IV'/04o V/N <br /> TH S pA/?-� <br /> MFNT <br /> I <br /> i <br /> DEPARTMENT USE,,ONLY j <br /> Application Accepted By/�- � Data 7 L 0.Lo Area ��r/ Employee ID# <br /> Grout Inspection By_ Date _ SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Sod Boning Inspection By /1L�. �..� Date ( �L Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Crwcil l Amount nate PermlU IRYOIGe/ Well IDD <br /> Codes Info B Cash Remitted 5 ice Request# <br /> S%,7 iSt7 C: <br /> En043-0E 6•tVY19 A wE:L rPtl7dp PERMIT <br /> ^'t'1`-'�I/J'////,,i • �l l� /.fes <br />