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0`-bCH U( <br /> WELUPUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95206-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.ggov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Lr CA <br /> D <br /> CROSS STREET NrL� A.Y e,,It R«\A APN 11 4��3�%� %RCELSIZE J dO LAND USE APPLICATION# <br /> OWNER NAME JSU 27 0 0,*—S PHONE <br /> OWNER ADDRESS 555 CAQ\� M4\` r Jt UIlit 1\00 CITY/STATEfZIP 4YAW1G'�'� Cf4 <br /> CONTRACTOR1n PHONE .ZO`1 <br /> CONTRACTOR ADDRESS To ?)CA,(�it'i? CITYISTATE/ZIP ttwW ICA <br /> t, 1S� <br /> SUBCONTRACTOR/CONSULTANT 1 %6YC.1l\C1 PHONE `�40-U\10)L_0 f i`Ool <br /> SUBCONTRACTORICONSULTANT ADDRESS 1LlU �GYIA�OQy++IK+G # 3 CIITYrSTTATE/ZIP-W•�UrY�\W L C t \5L 5 <br /> LICENSE ar C-57 ❑C-61 C D-09 0 Other NUMBER 6`- <br /> r001� _ EXPIRATION DATE <br /> BILLING PARTY: 7 OWNER D CONTRACTOR UBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE ❑DomesticlPrivate C Irrigation/Agricultural D Industrial 0 Water Quality Monitoring C Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK C New Well 0 Replacement Well .0 Well AlterationfModificetion 0 Other <br /> 0 Monitoring Well(s) // <br /> _#of wells 0 Soil Borings; , it of bon"g' Geotechnical 5 *or borings <br /> ❑Out-Of-Service Well C Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> ❑New Pump ❑Pump Reolacement ❑Purro Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rotary 0 Air Rotary gAuger D Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth—,-&S—ft Excavation I In diameter ❑Open Bottom D Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth fl <br /> Well Casing Diameter_in Thickness/ auge/ASTM Schad ❑Steel 0 Plastic D Stainless Steel 0 Other <br /> Grout Seal Depth X5 ft Neat Cement(94 lb beg310 gal water) 0 Sand Cement sack mixl7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method ❑Pumped 0 Free Fall 0 Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By C Driller ❑Pump Contractor ❑ Other <br /> D Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box C Stove Pipe <br /> PUMP ❑Submersible❑Turbine 0 Other HP Pump Set ft Standing Water Level It 1 <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 /> WORKEMPAINSATIC N LAWS. <br /> MINIM OU4DVNCE !TIC`F&REQUIRED FOR INSPECTIONS CALL(209)953-7697� DATE 24,1912V U— TITLE O I <br /> c+ <br /> � r <br /> I <br /> VAi <br /> I eo <br /> so <br /> 202G� <br /> C� <br /> A <br /> I RTMENT <br /> y h <br /> D P RTMENT USE E Oj1�+Ln�YJA <br /> / <br /> Application Accepted By Date Gt/ Area Employee ID# c/hI G <br /> Grout Inspection By Date 73 SPECIAL Well Permit <br /> Pump Inspection By Date_ WAIVER Received <br /> Soil Boring Inspection Byairn ma Date 9 Constructed Well Depth ft <br /> COMMENTS Ul <br /> PE Sc Received1 Amount Date Permit/ I Invoice# Well ID# <br /> Codes Info B tiCCash Remitted Ice Request# <br /> I IW1 WV00(k,&qS <br /> EH043.06 8/11/2019 WELL/PUMP PERMIT <br />