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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 A www.S OV.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 121 C IN /y• yi'll /TJe_ CrrY/ZIP LOsr, 1�Z y C1 m <br /> 1 <br /> CROSS STREET t V 1GI Qd APN / ZO Il ZPARCEL SIZE 4'.�LAND USE APPLICATION# p <br /> / m <br /> L <br /> OWNER NAME ' PHONE ,�} <br /> OWNER ADDRESS 1 L - � -�\ CITY/STATE/ZIP 5u.l�/l.`, �f�1t � ICA <br /> r/ <br /> CONTRACTOR n, /'�A aA"soo /.`'` ll `ffa�6^ PHONE(7Q!R) 7I1��C�� <br /> CONTRACTOR ADDRESS -t.O'2 j;Tn&SA r I G` 1JV� CITYISTATE/ZIP C CA t 2 y a 1 <br /> SUBCONTRACTOR/CONSULTANT CxMl. __OLS ab blip PHONE C.&OA- Q.S CwyO1,e <br /> SUBCONTRACTORICONSULTANT ADDRESS OLS owe— CITY/STATE/ZIP rack OA- d-'A G,bOV <br /> LICENSE 7-C-57 C-61 D-09 Other NUMBER (I**j 000 -k EXPIRATION DATE 5'%I-tot! <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)J Dibromochloropropane(4392)_Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Li 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 I 1 Replacement Well ❑ Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings 1Q Geotechnical of borings <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement ❑ 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 1T1"ZQ1 ft Excavation C. 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 'A Neat Cement(94 Ib bag/5-10 gal water) i Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method ! Pumped Free Fall i Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller -'. Pump Contractor Other <br /> Concrete Pedestal iiDimensions:Width ft Length ft Thick in Christy Box i, Stove Pipe <br /> PUMP Submersible Turbine 1! 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 /> MINIMUM 8 <O ADVANCE NOTICE REQUIRED FOR-INSPECTIONS -LPLEASE CALL(209)953-7697 <br /> SIGNED < TITLE Fft`�Ia�Si DATE I.17� 1�ZO <br /> XA. <br /> 1� <br /> V / <br /> N N <br /> r <br /> DEPARTMENT USE ONLY <br /> Application Accepted By C' yL` Date Z//,?,0 Z o Area Employee ID# <br /> Grout Inspection By Date _. SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date [CZP Constructed Well Depth ft <br /> COMMENTS y <br /> PE SC Received hecjq!V Amount Date Permit] Invoice# Well ID# <br /> Codes Info B as Remitted Service Request# <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />