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WELLIPUMP PERMIT G? � � -Z;Z/ <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAzELTON AVENUE-STOCKTON CA 95205-6232(209)4683420 <br /> NON-REFUNDABLE PERMIT �www-sjgov.org/ohd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS /S% ly/� �Y TVD /✓ CITYRIP <br /> / T <br /> CROSS STREET C- r APN OO�en V 03U PARCEL SIZE '5-LAND USE APPLICATION It o <br /> OWNER NAME _ J\/�/�¢ OV� PHONE <br /> OWNER ADDRESS -75r_ ITY/STATE21P <br /> CONTRACTOR �F7 �,I Xg&/F/7 2 PHONE <br /> i <br /> CONTRACTOR ADDRESS CITYISTATEIZIP <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/LP <br /> LICENSE C-57 a, 61 D-09 Other NUMBER V EXPIRATION DATE <br /> BILLING PARTY: OWNER ONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE omestic/Private Irrigation/Agricultural 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 Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Bonng(s) 0 o borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal :Cross-Connection Repair <br /> New Pum umpRe_placement _i 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 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 Plastic i Stainless Steel Other <br /> Grout Seal Depth ft I Neat Cement(94 Ib bag/rf 0 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall � Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By ,Driller r Pump Contractor Other <br /> Concrete Pedestal_Dimensions:Width It Length it Thick in Christy Box . Stove Pipe <br /> PUMP ubmersible Turbine Other. HP Pump Set ft Standing Water Level --ft <br /> I HEREBY CERTIFY THAT 1 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERSRMPATI I <br /> I%Al CE NOTICE REQUIRED FOR I PECTIONS-PLEASE CALL(209)9 3 69 <br /> SIGNED TITLE i/� DATE <br /> Orr <br /> NT <br /> ED <br /> 020 <br /> In <br /> Alp uNrY <br /> TAL <br /> WENT <br /> �T /J/ <br /> LEPARTMENT US5 ONLY �i f� n <br /> Application Accepted By �- Date E S ZL�Z� Area q %U Employee ID# L rii <br /> Grout Inspection By Date I SPECIAL Well Permit <br /> Pump Inspection By }U GrJ-vL '-t Date-�Vf 1,4tie) WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invotcc# Wcll ID# <br /> Codes Info Kash Remitted Service Re uest# <br /> U <br /> r <br /> FHO e3.da 8/112018 WELL I UMP PERMIT <br />