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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 www.si Ov.On /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS A I It lawCITY/ZIP <br /> D <br /> CROSS STREET APN 01 g 3 y00 I PARCEL SIZE JD-LANO USE APPLICATION# o <br /> AIJ AC-001 <br /> 9!Q 9 a m <br /> OWNER NAME U7 HON A y <br /> (+ f <br /> OWNERADDRESS CITY/STATEMIP riys aq 961)-1 <br /> CONTRACTOR Wzl, PHONE 3910 <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS lawenACITY/STATE/7IPC'iq <br /> SUBCONTRACTOR/CONSULTANT 44 PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE VC-57 ❑C-61 0 D-09 ❑Other NUMBER4&W--49 EXPIRATION DATE D 3 <br /> BILLING PARTY: ❑OWNER D CONTRACTOR ❑SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑Industrial a Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> Rdifferent from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells 0 Soil BOdng(s) #of borings ❑Geotechnical #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> ❑New Pump P ump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth ft Excavation 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 Schad ❑Steel 0 Plastic ❑Stainless Steel 0 Other <br /> Grout Seal Depth ft ❑Neat Cement(94 Ib bag/5-10 gal water) 0 Sand Cement sack mixll gal water <br /> 0 Bentonite(20%solids) 0 Other <br /> Grout Placement Method ❑Pumped 0 Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller 0 Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box 0 Stove Pipe <br /> PUMP Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> , 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. 1 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 C PE, SATIO LA <br /> MI OU NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)951g#97 <br /> SIGNED TITLE DATE '71n <br /> r <br /> 0 <br /> /JP I <br /> D-EPARTMENT USE ONLY <br /> Application Accepted By `�-� Date Area 7 '7 Employee ID#D_ <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By :j;0;d84 9.Z,, Date�p1 in ?UZ0 ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Recelved eck# Amount Date Permit/ Invoice# WeIIID# <br /> Codes Info B Remitted S ice R uest# <br /> os0 -17:2I ZU <br /> EHD 43-M 8/112019 WELL/PUMP PERMIT <br />