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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 3232(209)4683420�. <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED - <br /> _ La <br /> JOB ADDRESS {LYS. � CITVrjJ/p� f '7 �— 6�y <br /> CR OSS STREET ' N PARCEL SRE (-i LA1�USE APPLICATON# i7 <br /> M <br /> m <br /> OWNER NAME G PHONE <br /> OWNER ADDRESI-?-m LYvc,& 111CITY/STATEIZIP jzrL -- <br /> CONTRACTOR Con rXU6SUf(VlXl\ PHONE()IDZ(a 1-3�OAZy5 <br /> CONTRACTOR ADDRESS ISIO 14adeir 0-tow J <br /> CITY/STATE/ZIP_�1�,w) CA QS IP 26 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATEIZIP <br /> LICENSE WE57 ❑C-61 D D-09 ❑Other NUMBER Ci 54210'1 EXPB2ATION DATE <br /> BILLING PARTY: ❑OWNER Q40NTRACTOR D SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(43132)❑Arsenic(4393) <br /> INTENDED USE ❑DOmesWPrtvate ❑Irrigation/Agricultural ❑industrial ❑Water Quality Monitonrg NWSoii Sampling/characterization <br /> ❑Public Water System � <br /> N dieerent from ckvn r: Water System Name Contact Name w Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Afteratiort/Moda`cation ❑Other <br /> ❑Monitoring Weli(s) #of wells boil Boring(s) CofbOnngs geotechnical 2s ofbonrq <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement D Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool VOush Point ❑ Other C-P, <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 D Plastic ❑Stainless Steel a Other <br /> Grout Seal Depth50 it Q Aeat Cement(94 Ib bay5-10 gal water) ❑Sand Cement sack mW7 gal water <br /> 7 Bentonfte(20%solids) ❑Other <br /> Grout Placement Method umpecl ❑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 G Submersible[]Turbine ❑Other HP Pump Set ft Standing Water Level ft r, I (/i t <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 ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 11NIM RAD REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TRLE eSI DATE <br /> RE YMF <br /> MAR OS <br /> '14/V ?p <br /> AST 1U/V <br /> DEPARTMENT USIE O �L,Y(� <br /> Application Accepted By Date72 " Area I C /Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By_ Date_ ❑ WAIVER Received <br /> Soil Boring Ins on By _ Date Constructed Well Dept <br /> COMMENTSAAAAA4 —2hAi -f1ft <br /> PE SC Received eChecidlif Amount a PermlU Invoices WeIIID1' <br /> Codes Info Remitted Service Requests <br /> y wpoo <br /> END 4306 6/112019 WELL/PUMP PERMT <br /> l <br />