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WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABL ERMIT www.sjqov.org1ehd EXPIRES 1 YEAR FROM D TE ISSUED <br /> rn <br /> JOB ADDRESS U U7,419 CITY/ZIP ^' <br /> 1 D <br /> CROSS STREET _ APN 17 Z)20-2 PARCEL SIZE _LAND USE APPLICATION It z <br /> OWNER NAME PHONE <br /> OWNER ADDRESS _ CITY)STATE/ZI �D/�T <br /> CONTRACTOR (,{.�PH�O�N/E,�L1 � K�CTf (J <br /> CONTRACTOR ADDRESS CITY!$TATEiZIP !/VLJV►W///.CAN✓� <br /> SUBCONTRACTORICONSULTANT 14 PHONE <br /> SUBCONTRACT /CONSULTANT ADDRESS CI S TE IZIP <br /> LICENSE -57 C-61 D-09 Other NUMBER EXPIRATION DATE <br /> BILLING PA TY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DoMEsnc WELLS MPLING: General Mineral/Coliform Bacteria(4391) Dlbromochloropropane(4392) Arsenic(4393) <br /> INTENOED USE Domestic/Pnvate Imgahon/Agncultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> It e1R.rent I—Owner INW.r System N.M. Canted Name.,Ph...Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Bonng(s) 80 t—np Geote&nical a d borings <br /> Out-Of-ServiceII Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum Pum Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter_in Thickness%Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth h Neat Cement(94 Ib bag/5.10 gat water) Sand Cement sack mixn gal water <br /> Benionite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Onller Pump Contractor Other <br /> 7Concrete Pedestal Dimensions-Width R Length It Thick in Christy Bos Stove Pipe <br /> PUup _.T.Submersible Turbine Other HP Pump Set ft Standing Water Level f1 <br /> 1HEREBY CER+TIFY 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 /> WORK OMPENSATION <br /> MI MU4 R f70TIcE kUIRED F R NSP PLEASE CALL(209 -76 <br /> SIGNED TITL DATE <br /> IXI <br /> - MFNT <br /> 2o2V <br /> U <br /> Ov <br /> Tq4 Iy. <br /> FHT <br /> DEPA TMENT USE ONLY <br /> I �i <br /> Application Accepted By � Date � z�ZO Area � Employee lo# <br /> Grout Inspection By a Date SPECIAL Well Permit <br /> Pump Inspection By �CW-�j Sig f terga.fA.`2' Date G WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth it <br /> COMMENTS <br /> PE SC Received C Amount Date Permit/ Invoice# Well ION <br /> Codes Into By Cash Remitted Se i Re,uest# <br /> _91K _.V <br /> EHDA3.06 61tt2019 WELL/pump PERMIT <br />