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151'0 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABq PERMIT WWW.S OV Or /ehd rEXPIRES 'I YEAR FROM DATE ISSUED <br /> J <br /> JOB ADDRESS h r► S m Ct CITY/ZIP ��` tL IA (` 04 ✓ V m <br /> r' D <br /> n,�l APN 3�� ^t PARCEL SIZE LAND USE APPLICATION# A <br /> CROSS STREET (L�y 1e /`��t Oa ''O� o <br /> OWNER NAMEU I J1 UPHONE <br /> OWNER ADDRESS n�A✓S ,rn a I 1 CITY/STATE/ZIP C O� ^ <br /> CONTRACTOR L / u V- " r v` ✓ PHO ' 7 v'-j V \`+V <br /> CONTRACTOR ADDRESS ✓ 0 1 ` C(4 CITY pSTAT /Z C1 /550 <br /> SUBCONTRACTOR/CONSULTANT PHONE• " <br /> IV <br /> SUBCONTRACTOR/CONSVC-61 <br /> T ADDRESS CITY/STATEIZIPM <br /> LICENSE _ 60-57 _ D-09 L Other— D21 N—um BL�_� �L+ EXPIRATION DATE P 2v v ' <br /> BILLING PARTY: OWNER CONTRACTOR I SUBCONTRACTOR/CONSULTANT <br /> DO IESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) = Dibromochloropropane (4392)CI Arsenic(4393)oe <br /> S <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 a Replacement Well [_l Well Alteration/Modification -1 Other <br /> Monitoring Well(s) #of wells n Soil Boring(s) #of borings - Geotechnical #of borings <br /> Out-Of-Service Well aPut-Of-Service Well Renewal L1 Cross-Connection Repair <br /> New Pum ❑ Pump Replacement X.PumpRepair C Raise Well Casing <br /> WELL CONSTRUCTION a` <br /> Drilling Method _ Mud Rotary I_I Air Rotary a Auger Cable Tool L. Push Point Other <br /> Proposed Well Depth ft Excavation in diameter _j Open Bottom I_ Gravel Pack/Gravel Size in diameter <br /> _ Conductor Casing in diameter / Conductor Casing Depth ft r <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched _I Steel I Plastic _ Stainless Steel a Other N <br /> n <br /> Grout Seal Depth ft n Neat Cement(94 Ib bag/5-10 gal water) 1 Sand Cement sack mix/7 gal wat 17-4 <br /> - Bentonite(20%solids) J Other <br /> Grout Placement Method - Pumped rl Free Fall -1 Other n Retardant/Accelerator(name) <br /> PEDESTAL Installed By -- Driller ❑ Pump Contractor C Other <br /> Concrete Pedestal LIDimensions:Width ft Length ft Thick in Christy Box a Stove Pipe <br /> PUMP Submersible- Turbine n 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 C <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 COMPENSATI N LAWS. <br /> IN UM 48 DV NCE NOTICE REQUIRE F(�fit INSPECTIONS -PLEASE CALL (209) 953-7 97 <br /> SIGNED TLE ✓ '�2/Y�/NQS L C • " DATE d <br /> Ell/ <br /> A <br /> N <br /> F N <br /> R <br /> I I I I I I I I I I I I I 1 1 I I I I I I I � I I I I I I I I I I I I I I L_I I MFNT I I I <br /> DEPARTMENT USE ONLY <br /> Application Accepted By �� 7Z/�L� Date Area SA Employee ID# SK <br /> Grout Inspection By Date --1 i 0 SPECIAL Well Permit <br /> Pump Inspection By "nl.�V UL-fu e, .`L Date J WAIVER R@CBIVed <br /> Soil Boring inspection By Date Constructed Well Depth ft <br /> COMMENTS A p j 3d <D J 0 a }I rec <br /> PE SC Received hec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info as Remitted ervice R ue # <br /> 43�'a o 477 f <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />