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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 /> T <br /> JOB ADDRESS ' - ' `� "` CrrY/ZIP l�JC"� 4 <br /> ,I� >b� <br /> m <br /> � y� !l D <br /> CROSS STREET'4yy' ..'4� ->`�`�', I APN��e'Ii`D 0 Y PARCEL SIZE\)'A ri'rLAND USE APPLICATION# p <br /> OWNER NAMEFSVLr PHONE <br /> OWNER ADDRESS L)J� F'P e 1,j boc/ D r CITY/STATE/ZIP ' <br /> CONTRACTOR ly�ll r-Sa\ UUnbtnl r.�"S PHONEIn <br /> -'�,o( <br /> CONTRACTOR ADDRESS 1-h�U��r'C���\ W� CITYISTATE/ZIPS <br /> SUBCONTRACTOR/CONSULTANT 1� PHONE 1�Ili <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 1�! CITY/STATE/ZIP / <br /> LICENSE C-57 C-61 D-09 Other NUMBER EXPIRATION DATE <br /> BILLING PARTY: /,wWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: _General Mineral/Coliform Bacteria(4391)_l Dibromochloropropane(4392)_Arsenic(4393) <br /> INTENDED USE - Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring XSoil 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 ❑ Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings �(Geotechnical Li #of borings <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement "1 Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION #Ab <br /> —rye- <br /> Drilling Method Mud Rotary Air Rotary Auger i Cable Tool Push Point Other <br /> ! <br /> Proposed Well Depth V ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size <br /> Conductor Casing in diameter / Conductor Casing Depth ft !� <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other M'7 <br /> AY <br /> Grout Seal Depth v, ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sas�ix6Aal water O�Q <br /> Bentonite(20%solids) Other _ E QV/ U <br /> Grout Placement Method �, Pumped )A Free Fall Other T�'y"te Retardant/Accelerator(name) T MF N7y <br /> PEDESTAL Installed By a Driller i.i Pump Contractor Other ENT <br /> Concrete Pedestal 11 Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <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 /> i1g1NIMU/I�yI148,HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 953-7697 <br /> SIGNED J�✓ TITLE ,Slr}Tt G('QID I,S DATE -� -�0 <br /> Ft <br /> i <br /> V <br /> ME- <br /> DEPARTMENT USE ONLY <br /> Application Accepted By ` - Z' Z_ Date 1� Zozo Area -1 Employee ID# <br /> Grout Inspection By Date _. SPECIAL Well Permit <br /> Pump Inspection By Date c WAIVER Received <br /> Soil Boring Inspection By Date J Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received he Amount Date Pertn1U Invoice# Well ID# <br /> Codes Info Py Cash Remitted ervice Re uest# <br /> Y <br /> �37a �,j� I � � <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />