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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 (� 1 www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> 1 U/ \Xl` -y �Ut�Lke CrrY/ZIP S�1��Alin C41 hJ '�Ub m <br /> 'J 101h S teep ' &5 0 <br /> CROSS STREET APN PARCEL SIZES ��B LAND USE APPLICATION# M <br /> m <br /> (a <br /> OWNER NAME PHONE P! <br /> OWNER ADDRESS `�p 1 CITY/STATE/ZIP <br /> CONTRACTOR I l, a� �{J,1�U,TCnI'� (�IZ) I PHONE <br /> CONTRACTOR ADDRESS ` Z`�+V`Sr1l r1` W CITY/STATE/ZIP LOA , I �} uv <br /> SUBCONTRACTOR/CONSULTANT `y PHONE `� 'I <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 1`� 6�A�LCITYISTATE21P N',I <br /> .�1 EXPIRATION DATE <br /> LICENSE �(C-57 C-61 D-09 Other_ NUMBER _ <br /> BILLING PARTY: -,\OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: _General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)-Arsenic(4393) <br /> INTENDED USE Domestic/Private 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 _. Replacement Well I Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells I Soil Boring(s) #of borings )C Geotechnical T� #of borings <br /> Out-Of-Service Well I Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement I Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary - Air Rotary �Auger Cable Tool ❑ Push Point Other <br /> Proposed Well Depth S� It Excavation in diameter ❑ Open Bottom 0 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 Plastic Stainless Steel - Other <br /> Grout Seal Depth r ft )C Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method �,Pumped Free Fall I I Other L `� Retardant/Accelerator(name) <br /> PEDESTAL Installed By _I Driller I Pump Contractor Other <br /> U Concrete Pedestal I!Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP n Submersible_. Turbine Other HP Pump Set ft Standing Water Level ft <br /> I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORD 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 /> tu11MUM ��y�/y/r�1+U +APVyA�NCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 95113-7697 1 <br /> SIGNED (�/✓�- / ' V l/ l TITLE <br /> DATE <br /> l � <br /> App <br /> Eo <br /> S ?020 <br /> T Fu/vey <br /> MFN t <br /> DEPARTMENT USE ONLY <br /> i <br /> Application Accepted By ' � Date ii G ZO" Area ' A� Employee ID# <br /> Grout Inspection By Date _ SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring In�ection By C _ Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Casfi Remitted Service Request# <br /> yslC,(' i.� z2 rCL wei1 �t. <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />