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WELL/PUMP PERMIT <br /> SAN JQ'AQUIN CbUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS ' CITY/ZIP -1-r1�-�� "l�"7 3 We m <br /> W. O --1 1 g <br /> CROSS STREET `frL11Ck Ca►•W%_0 KA• APN ZO3" 10 O •- 1 PARCEL SIZE .94 LAND USE APPLICATION# p <br /> OWNER NAME � cn h;'Ir Gr DC )O PHONE 9 L 8 <br /> OWNER ADDRESS .aa� CITY/STATE/ZIP_K{ Van. C fk 0165"n <br /> CONTRACTOR ' Ur O Cp. C • PHONE 545 - 1 18 b <br /> Q <br /> CONTRACTOR ADDRESS 1_`3 L. CITY/STATE/ZIP yn O a C 54-a l CA 9 s3 S1 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE �-57 C-61 � D-09 L2-0t08I Other NUMBER 08 13 EXPIRATIONDATE <br /> BILLING PARTY: ]OWNER ONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELLS PLING:K General Mineral/Coliform Bacteria(4391)A Dibromochloropropane(4392)L, Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural 1. Industrial r i Water Quality Monitoring Soil Sampling/Characterization <br /> L Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORKNew Well i., Replacement Well 11 Well Alteration/Modification i Other <br /> 1 Monitoring Well(s) #of wells Soil Boring(s) #of borings ; Geotechnical #of borings <br /> Out-Of-Service Well %i Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement L Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary '. Auger LI Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation ILJ in diameter I Open Bottom `(X",*Gravel Pack/Gravel Size No• in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter$ in Thickness/Gauge/ASTM SchedSO9.Z 1 11 Steel Xlastic -- Stainless Steel ❑ Other <br /> Grout Seal Depth .2,4E)0 ft Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) -1 Other <br /> Grout Placement Method umped -i Free Fall a Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By a Driller Pump Contractor L Other <br /> Concrete Pedestal ]Dimensions:Width ft Length ft Thick in ❑ Christy Box `J Stove Pipe <br /> PUMP L Submersible❑ Turbine ! 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 ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUI D F INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED bui. ` 87�0ITLE V DATE I r h1J <br /> 129. <br /> a <br /> r <br /> r <br /> q � 0 <br /> C <br /> F N <br /> 41111 - 44UH4H <br /> DEPARTMENT USE ONLY <br /> Application Accepted By !- �l L Date 716 IdOdD Area__ Employee ID# "i K <br /> Grout Inspection By 41 e..� Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS -� - Mab• //Cf b <br /> cs /-� J.� �� ✓7c CLN fir•, r� <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> �3a 180 `Ido <br /> H3C3► <br /> .3`- N <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT , <br />