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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-FWFUND#BLE PERMIT www.sjgov.org/ehd `!EXPIRES 1 YEA/R�FROM DATE ISSUED <br /> JoErADDRESS �f <br /> CITY/ZIP Y/w/ /�l �%v: rt�l <br /> r t (((��� `'�'� <br /> CROSS STREET APN PARCEL SIZE �I YILAND USE APPLICATION# A <br /> OWNER NAME i PHONE H <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR l\& ! PHONE //,,q--LAV -�-S\ <br /> CONTRACTOR ADDRESS '/ ✓l +' lF�V�6YT 1'C �lN\i {he CITY/STATE/ 1P ll/rl L.'�I df <br /> SUBCONTRACTORICONSULTANT �_'YnQCA` �;Ir�t,t/t-\ PHONE,1 <br /> SUBCONTRAC�TORRICONSULTANT ADDRESS J TTT CRY/STATE/ZIPT r T� /%A In. <br /> 515 <br /> LICENSE L�'C-b7 C C-61 n D-09 D Other NUMBER EXPIRATION DAT <br /> BILLING PARTY: 0 OWNER D CONTRACTOR D SUBCONTRACTOR/CONSULTANT IF bPLO <br /> DOMESTIC WELL SAMPLING:D General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE D Domestic/Private D Irrigation/Agricultural D Industrial D Water Quality Monitoring Aa Sampling/Characterization <br /> D Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK D New Well D Replacement Well D Well Alteration/Modification D Other <br /> D Monitoring Well(s) #of wells D Soil Borings) #of borings Geotechnical #of borings <br /> D Out-Of-Service Well D Out-Of-Service Well Renewal D Cross-Connection Repair <br /> D New Pump D Pump Replacement 7 Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method V(MUd Rotary C Air Rotary � Auger D Cable Tool Vl<ah Point C Other <br /> Proposed Well DepthIN 4p ft Excavation in diameter 7 Open Bottom D Gravel Pack/Gravel Size in diamet <br /> I I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter n _T17ickness/Gauge/ASTMSched 7 Steel D Plastic ❑Stainless Steel D Other /1���f�VV <br /> Grout Seal Depth y►��y'l M,<..t Cement(94 lb bag/5-10 gal water) �Sand Cement Sack mixr7 gal water 6► E® <br /> 0 Benton, ( o solids) C Other <br /> Grout Placement Method f<umped C Free Fall Oth C Retardant/Accelerator(name) 0 2019 <br /> PEDESTAL Installed By D Driller D Pump Contractor 7 Other <br /> U Concrete Pedestal UDimensions:Width ft Length ft Thick in L Christy BOX L Stove PI V(N CO <br /> uNry <br /> PUMP I I Submersible I Turbine I Other HP Pump Set ft Standing Water Level NpMEN-rAL <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN EF,gRT4gENT <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 /> MINIMUW48 HOUR ADVANCE NOTICE REQUIRED FOR INSP CTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE <br /> AR MENT U E ONLY <br /> • <br /> Application Accepted By ate a Area Employee ID# <br /> Grout Inspection By Data IF ❑ PECIAL Well Permit <br /> Pump Inspection By Date /_ F1 WAIVER Received <br /> Soil Boring Inspection By t�C-��/L� Date G / l v/ �v Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount D tPermit/ Invoice# Well ID# <br /> Codes Info Cas a itt o Service Re uest# <br /> EHO 43-08 61111112019 /�'�-.. �/����� WELL(PUMP PERMIT <br />