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t <br /> 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.S Ov.or /ehd EXPIRES 1 YEAR FROM RUE ISSUED <br /> JOBADDRESS ` V CITYIZIP <br /> CROSS STREET APN PARCEL SIZE ( LAND USE APPLICATION# o <br /> m <br /> OWNER NAME +PHONE <br /> OWNER ADDRESS CITYISTATEIZIP <br /> y <br /> CONTRACTOR //y;>C) Cl 'UhsuCGiziptis i PHONEg1(P 7(01-3( ZO) <br /> CONTRACTOR ADDRESS ISID 14ad Q, I CIY/STATEZIP fJ yD j) V y+ <br /> GU <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRAC__TORRICONSULTANT ADDRESS CITY/STATEIMP <br /> LICENSE �;Y667 ❑C-61 ❑0.09 0 Other NUMBERGS92tn1 EXPIRATION DATE01/31 ,O <br /> BILLINGPARTY: ❑OWNER Q.GbNTRACTOR ❑SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTEnroED USE ❑Domestic/Prlvate ❑1migation/Agricultural ❑Industrial ❑Water quality Monitoring Wlgoll Sampling/clara"t ,ization <br /> ❑Public Water System <br /> If difrerent from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well ❑Replacement Well ❑Well AReration/Modification ❑Other <br /> ❑Monitoring Wells) #of wells Q6oil Borings) xofbonti 04eotechnical •ofbwngs <br /> 0 Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> 0 New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool V-Push Point ❑ Other Gp't' <br /> Proposed Well Depth it 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 0 Stainless Steel 0 Other <br /> Grout Seal DepthC) It Q Aeat Cement(94 Ib bag/540 gal water) ❑Sand Cement sack mix/7 gal water <br /> 0 Bentonite(20%solids) ❑Other <br /> Grout Placement Method umped ❑Free Fall ❑Other U Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ftThick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level _ ft <br /> 1 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 ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL -'- <br /> WORKERS COMPENSATION LAWS. <br /> MINIM W48 R ADV/►NrE N^Tr^F REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED _ TITLE ���4t�+�'{ DATEZ/ <br /> 11111 HIM <br /> RF yMF <br /> CEjV�T I <br /> AR 05 7420 <br /> Q�N COdFFgR �TY <br /> T <br /> PARTMENT U E NLY �j <br /> Application Accepted By , Date Area �/ ployee I❑# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> IS <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Ins By ection Date Con-sttructed Well Depth ft <br /> COMMENTS <br /> AMC�-(„ C),S— <br /> • <br /> PE SC Received Amount at Permit/ InvoCe* Well Mi <br /> Codes Info s Rem Service Requi <br /> EHD 43-06 61112019 WELL PUMP PERMIT <br />