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Ad off, <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 <br /> a a a a <br /> www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS /ar � 1 <br /> m <br /> m <br /> !� D <br /> CROSS STREET P,11�0 i APN i� I'y��/I PARCEL SIZE R 0"C1 LAND USE APPLICATION <br /> Ej# A <br /> UI • 1O ONE V m <br /> OWNER NAME uy <br /> (�j m <br /> OWNER ADDRESS J + ' -�/�/ v CITY/STATAP� <br /> CONTRACTOR PHONE I?D -1C� od o C <br /> CONTRACTOR ADDRESS TLA /I CITY/STATE/ZIP S-tv <br /> OGS <br /> SUBCONTRACTOR/CONSULTANT / PHH�ONE w l� <br /> SUBCONTRACTOR/CON1SUL7ANT ADDRESS CITY/STATE/ZIP r t Lyq <br /> LICENSE _ C-57 V U C-61 _ D-09 Li Other NUMBER d ® EXPIRATION DATE U 2,,4) ^^ <br /> BILLING PARTY: OWNER CONTRACTOR 1 SUBCONTRACTOR/CONSULTANT Y <br /> DOMESTIC WELL SAMPLING: D General Mineral/Coliform Bacteria (4391)- Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE _ Domestic/Private U Irrigation/Agricultural _ Industrial _ 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 U Replacement Well U Well Alteration/Modification -i Other <br /> Monitoring Well(s) #of wells n Soil Boring(s) #of borings - Geotechnical #of borings %,A_ Out-Of-Service Well U Out-Of-Service Well Renewal U Cross-Connection Repair <br /> = New Pume X Pump Replacement ❑ Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method _ Mud Rotary U Air Rotary U Auger _ Cable Tool L Push Point _ Other <br /> Proposed Well Depth ft Excavation in diameter D Open Bottom L Gravel Pack/Gravel Size in diameter <br /> _ Conductor Casing in diameter, / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched J Steel U Plastic _ Stainless Steel U Other <br /> Grout Seal Depth ft n Neat Cement(94 lb bag/5-10 gal water) F1 Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) D Other <br /> Grout Placement Method - Pumped F1 Free Fall Fl Other n Retardant/Accelerator(name) <br /> PEDESTAL Installed By -- Driller ❑ Pump Contractor E Other <br /> _ Concrete Pedestal UDimensions:Width ft Length ft Thick in _ Christy Box U Stove Pipe p <br /> PUMP Submersible- Turbine n Other HP_j Pump Setft Standing Water Level ft Q <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 CC#PENSATION LAWS. <br /> MIM dHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED �. ` TITLE ` I�LS� ' / '�/y DATE <br /> t - <br /> Lj Ll <br /> V <br /> I <br /> ! T <br /> t <br /> km <br /> i <br /> 14AV/�^,UlAf <br /> U <br /> T4 4t <br /> i <br /> DEPARTMENT US ONLY �r / <br /> Application Accepted By ����li Date 3� 1026 Area G% Employee ID# DA <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date b(�S(��2J ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Re uest# <br /> 7 2 MUD <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />