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WELL/PUMP PERMIT <br /> O SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-UEUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS/t CITY/ZIP m <br /> CROSS STREET APN PARCEL SIZE LAND USE APPLICATION# <br /> m <br /> OWNER NAME PHONE vN,+ <br /> OWNERADDRESS T' \ CITY/STATE/ZIP <br /> CONTRACTOR K1rf.Jt d\�\(2)f � PHONE <br /> CONTRACTOR ADDRESS�0TrkV?6Y`7 t{ �tl.\[ 'u0 CITY/STATE21P�T . <br /> SUBCONTRACTOR/CONSULTANT _YnQCA` �Y: �.n PHONE <br /> 17F j77 -01, <br /> SUBCONTRACTORICONSULTANT ADDRESS J CITY/STATE/ZIP TMn Ty,.�, ��1 6 1^- <br /> LICENSE VC157 ❑C-61 ❑D-09 D Other NUMBER�� EXPIRATIO DATE <br /> BILLING PARTY: D OWNER D CONTRACTOR ❑ SUBCONTRACTORICONSULTANT b O <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)D Dibromochioropropane(4392)D Arsenic(4393) <br /> INTENDED USE D Domestic/Private D Irrigation/Agricultural D Industrial D Water Quality Monitoring oil 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 Boring(s) #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 ❑Pump Replacement 7 Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> S� <br /> Drilling Method VMud Rotary C Air Rotary VAuger D Cable Tool /Push Point C Other <br /> Proposed Well Depth ft Excavation in diameter 7 Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> I i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Toickness!/Gauge/ASTM Schad 7 Steel 7 Plastic D Stainless Steel D Other <br /> Grout Seal Depth ft [V eat Cement(94 lb bag/5-10 gal water) -1 Sand Cement sack mixl7 gal water <br /> D Bentoni 'o solids) C Other <br /> Grout Placement Method g'fumped C Free Fall D Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller D Pump Contractor 7 Other <br /> U Concrete Pedestal UDimensions:Width ft Length ft Thick in _Christy Box L Stove Pipe <br /> PUMP i I Submersible i Turbine 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 /> MIN IMU 48 UR ADVANCE NOTICE REQUIRED FOR INSPFCTIONSc-PLEASE CALL(209)953-769 <br /> SIGNED TITLE �.✓) \�`�'CL• DATE a <br /> y�FNr <br /> F/VFO <br /> 2419 <br /> / cq4IV <br /> IV47. <br /> EPA TMENT USE ONLY <br /> Afb�4" <br /> Application Accepted By ateArea Employee ID# <br /> Grout Inspection By Date ❑ PECIAL Well Permit <br /> Pump Inspection By Date—/_ �/�/ ❑ WAIVER Received <br /> Soil Boring Inspection By at. In 1 /il/ Constructed Well Depth ft <br /> COMMENTS �T <br /> PE SC Received Check#/ Amount D to Permit/ Invoice# Well ID# <br /> Codes Info B Casjh Remittolft. Service Re uest# <br /> _1 <br /> EHD 43-0fi 6/11!2019 - J WELL/PUMP PERMIT <br />