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N A ! QS 17+ <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)4683420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> / L 5 m <br /> JOB ADDRESS �Z.G 3 F45'& er- ee. CRY/ZIP m <br /> CROSS STREET '`et4t,,//4/� ISA LAC .I�Y�C'.1��APN 132070 1 O PARCEL SIZE 1`C" LAND USE APPLICATION# A <br /> OWNER NAME —}'LAA /_ p / I AP'HONE I- _ r I / �? <br /> OWNER ADDRESS IIA Lklot-brook lAr(�O �r ��14 � CITY/STATE/ZIP V"Q S� 7^WL [ L CDl <br /> CONTRACTOR I O ' AJe4.5 o '.I PHONE /��'✓/?) 3 6 7 -' 3 70 <br /> CONTRACTOR ADDRESS QO Z lno -�rl apt/ w CITY/STATE/ZIP L-oct / (-A / //E?,4O <br /> SUBCONTRACTOR/CONSULTANT IV ZA /Q PHONE� <br /> SUBCONTRACTOR/CONSULTANT ADDRESS N,/• 1 CR ,r <br /> 1`�Y/STATE/ZIP /A C <br /> LICENSE ){C-57 C-61 D-09 Other NUMBER 66 0 EXPIRATION DATE J_ 24 <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: _General Mineral/Coliform Bacteria(4391)_I 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 ❑ Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings X Geotechnical / #of borings <br /> Out-Of-Service Well ❑ 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 X Auger'e Cable Tool ❑ Push Point Other <br /> Proposed Well Depth7V^l�ft Excavation A-1- _b r, in diameter ❑ Open Bottom 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 ft }(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 Other i 2. Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> L Concrete Pedestal (Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP ❑ Submersible; Turbine i.i 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 /> MINIMU 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209)953-7697 <br /> `wry/ <br /> SIGNED 1 TITLE 0.L DATE <br /> ( r- i k. / 11- -1 <br /> CAM I IV FFF r <br /> VrA <br /> 0 <br /> / D PA�RTMENT US - N L Y <br /> Application Accepted By Date L w Area Employee ID# (J4h`C <br /> 4 <br /> Grout Inspection By T I Date L SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection BY, Date 6 f I Z/ �i� ^-�-�•"rtes+Wall Oeoth ft ... <br /> COMMENTS <br /> Pt 0�: Received ec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Remitted Service Re uest# <br /> ti i✓� W <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />