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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 /> NO N-REFU N DABjIE PERMIT t W,1!y_W.Sjg0V.org1ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> IV 1 LA�n �) / ,3 m <br /> JOB ADDRESS I Y { " CITY/ZIP "�CJ `/ c53 <br /> CROSS STREET �/V•"'y� p *PN odd d 3loo3 o PARCEL SIZE �'�" , LAND USE APPLICATION# <br /> OWNER NAME O a1 r � 1i () C `�V ` --sPHONE14o — -2 GG��J y <br /> 01 <br /> OWNER ADDRESS lb • �' CITY/STATE/ZI 4/' r+fC� � <br /> • 15 <br /> CONTRACTOR ! J I J ° �' PHONE ✓ / �V OZOqvuv �-tv CA <br /> n <br /> CONTRACTOR ADDRESS56q 7U4 CITY/STATEIZIP 55-6 V 9 <br /> SUBCONTRACTOR/CONSULTANT -M PHONEtl") // <br /> SUBCONTRACTOR/CONS`ULT/ANT ADDRESS CITq(Y/STATE2IP <br /> i'b M a <br /> LICENSE - C-57 V i C-61 _ D-09 Other ' NUMBERZl t/ (0 IP O EXPIRATION DAV `� <br /> BILLING PARTY: -OWNER CONTRACTOR 1 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELLS PLING: ❑General Mineral/Coliform Bacteria(4391) = Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE 41 Domestic/Private a 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 L Replacement Well U Well Alteration/Modification : Other51 <br /> - Monitoring Weil(s) #of wells n Soil Boring(s) #of borings - Geotechnical #of borings <br /> _ Out-Of-Service W II U Out-Of-Service Well Renewal j Cross-Connection Repair <br /> = New Pump Pump Replacement 0 Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> (Drilling Method _ Mud Rotary U Air Rotary ! Auger _ Cable Tool L Push Point _ Other n <br /> Proposed Well Depth ft Excavation in diameter J Open Bottom U Gravel Pack/Gravel Size in diameter Q <br /> _ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched _j Steel U Plastic _ Stainless Steel U Other <br /> Grout Seal Depth ft n Neat Cement(941b bag/5-10 gal water) i.-I Sand Cement sack mix17 gal water <br /> - Bentonite(20%solids) 7 Other <br /> Grout Placement Method - Pumped n Free Fall n Other n Retardant/Accelerator(name) <br /> PEDESTAL Installed By = Driller 0 Pump Contractor C Other <br /> Concrete Pedestal❑Dimensions:Width ft Lengt ft Thick in _ Christy Box L Stove Pipe <br /> LPuMP Submersible- Turbine -1 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 TIV WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COM S ION LAWS. <br /> MINI HOUR DVANCE NOTICE REQUIRED FO INSPECTIONS -- PLEASE CALL (209973-7§P7�J�� <br /> SIGNED TITLE Z ]V " "`Q '' `a 1/1 DATE W <br /> r� <br /> A J <br /> I I i t I I I I I I I I l I l l l l l l l l l l l IH V1. HQ ,V1 <br /> DEPARTMENT USE ONLY ® pgRtMNT <br /> Application Accepted By I--2'r j1 Z_ Date 6 as�i0o�� Area M�� Employee ID# S1r <br /> Grout Inspection By Date [ISPECIAL Well Permit <br /> Pump Inspection By �r L ljIn (,u/�+�♦ �L��` Date 1917;10 ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS Pafle4a;,f,firte S 9f G1lly wG.7el. <br /> PE Sc Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Re best# <br /> 4381 Ora 362SO 477T5 N <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />