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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.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> fl I L" Ln <br /> JOB ADDRESS &iL � /Ai� CZ'WG/l m <br /> CITY/ZIP/ K//�`,y�, m <br /> sem, D <br /> CROSS STREEdmw APN �� a S o03 PARCEL SIZE S a S' LAND USE APPLICATION# o <br /> m <br /> OWNER NAME PHONE !�!�/��O!- / ( Cn <br /> CA <br /> OWNER ADDRESSD l./CJ1C (/� CITY/STATE/ZIP <br /> CONTRACTOR r G4 <br /> PHONE/ ( /�Ll�f�j"�jlt/Z <br /> CONTRACTOR ADDRESSW4ax 1 CITY/STATE/ZIP /�JV/// <br /> SUBCONTRACTOR/CONSULTANT PHONE 44 <br /> SUBCONTRACTO /CONSULTANT ADDRESS CI Y/STATE/ZIP / <br /> LICENSE -57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br /> BILLING PARTY: OWNER ' i CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane (4392) Arsenic(4393) <br /> 11 <br /> INTENDED USE Domestic/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 ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-ServiceV�lell F-1Out-Of-ServiceWell Renewal Li Cross-Connection Repair <br /> ❑ New Pum Pum 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 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 Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 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 ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal[]Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine ❑ Other HP 11 Pump Set ft Standing Water Level ft <br /> I HEREBY C RTIFY 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 /> M 8 DVANCE NOTICE REQUIRED FOR I�N�SAPECTIONS -PLEASE CALL (209) 99S/3-7997 <br /> SIGNED TITLE I DATE f� <br /> NZ <br /> Our L <br /> l <br /> 04 <br /> NJ <br /> VI /N <br /> DEPARTMENT US ONLY �FpgRNTAC <br /> MFNT - f <br /> Application Accepted By � /G U L— Date C Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By e CS r C_oc Ldy,c. Date —7�q'12Q 2 ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received heck Amount Permit/ <br /> Codes Info B Cash Remitted Date ervice Re u t# Invoice# Well ID# <br /> 3$1 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />