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/tckprri <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 / / vvw.S OV.Or /ehd EXPIRES 1 YEAR/FROM DATE ISSUED <br /> a 17 v, t st ft l/' , CITY/ CCA/'o _ 0 N <br /> JOB ADDRESS � � <br /> /� m <br /> CROSS STREET /�� Y I1 � A N o a1c�3H D <br /> ,Q +�� �P/ARCEL SIZE �� LAND USE APPLICATION#1 O <br /> OWNER NAME "' an 'G `��tA r P ONE�-7(�—9` y <br /> / y� ,�) 14 <br /> n �� /f )� (� m <br /> OWNER ADDRESS / Y UV 1 1 �'' `� CITY/STA 1`l �`'� Y t <br /> CONTRACTOR IL <br /> It O rSM b4 rt)) S PH NE �VV "4 <br /> ',{ 1 <br /> CONTRACTOR ADDRESS "" �• CITY/STATE/ZIP �� <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS / I 7 7 CITY/SDT�ATT/E/ZI Y o '1 r� <br /> LICENSE _ C-57 L(C-61 D-09 U Other L NUMBER v ""' EXPIRATION DATE J' �� A <br /> ti <br /> BILLING PARTY: OWNER CONTRACTOR 1 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) = Dibromochloropropane (4392)U Arsenic(4393) <br /> INTENDED USE �q{Domestic/Private a Irrigation/Agricultural _ Industrial _ Water Quality Monitoring _ Soil Sampling/Characterization <br /> _`Public Water System S <br /> If different from Owner: Water System Name Contact Name or Phone Number (l <br /> TYPE OF WORK _ New Well U Replacement Well a Well Alteration/Modification _i Other <br /> - Monitoring Well(s) #of wells n Soil Boring(s) #of borings - Geotechnical #of borings <br /> Out-Of-Service Well U Out-Of-Service Well Renewal Li Cross-Connection Repair f1 <br /> New Pump X Pump Replacement ❑ Pump Repair C Raise Well Casing .� <br /> WELL CONSTRUCTION Q <br /> Drilling Method _ Mud Rotary U Air Rotary U Auger _ Cable Tool L Push Point _ Other <br /> Proposed Well Depth ft Excavation in diameter _j Open Bottom L. Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 1 Steel 11 Plastic _ Stainless Steel U Other <br /> Grout Seal Depth ft n Neat Cement(94 lb bag/5-10 gal water) n Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other f <br /> Grout Placement Method - Pumped n Free Fall n Other n Retardant/Accelerator(name) c� <br /> PEDESTAL Installed By - Driller ❑ Pump Contractor U Other j <br /> Concrete Pedestal UDimensions:Width ft Length ft Thick in _ Christy Box U Stove Pipe lU <br /> PUMP Submersible- Turbine n Other HP -J 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 ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP S TION LAWS. <br /> MINIM S HOUR ADVANCE NOTICE REQUIRED FO,F INSPECTIONS -PLEASE CALL (209)_953-769' <br /> 209 '-3-761 <br /> SIGNED TITLE DATE <br /> 1T� <br /> 31� <br /> If IA. <br /> r <br /> 1 <br /> r <br /> A <br /> �O�MENTAL <br /> 7Y <br /> DEPARTMENT USE ONLY <br /> ' ����E <br /> Application Accepted By L l—L_ Date ,2Jab Area q Employee ID# SK <br /> Grout Inspection By Date U SPECIAL Well Permit <br /> Pump Inspection By }i L��';S�� lj fi R+y';�- Date U WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received 'Ch eck# Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B as Remitted Service Request# <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />