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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELToN AVENUE-STOCKTON CA 95205.6232(209)4683420 <br /> NON-REFUNDABLE PERMIT L I www.sj ov /Ag.or /ehd EXPIRES 1 YEAR/FROM�jDATE ISSUED <br /> rXtt <br /> Joe ADDRESS I Z) I�_ p `J r L Nn/ , I L7 A r 1✓c— Cr ymp Ly�. / / > 2 TO <br /> CROSS STREET C V 1 Gy)I,c�r M1� APN V Y I `O f Z PARCEL SIZE �C LAND USE A(PP[UCATION# <br /> OWNER NAME �,2I>/rC� //�� II PHONE ` V�II� �^( b vyQl///�✓ <br /> OWNER ADDRESS c4 E C- �b 6 CITy/STATE/ZIP �un 1114 VCr(g, CA .140 91 <br /> CONTRACTOR oN e.� Aid ellSun i k so(- g4z( PHONE (((z o�,� 36T/37 o I <br /> CONTRACTOR ADDRESS ) D2- Z r JUu (r'-I <br /> L Lv�`�I CRY/STATEMP LG G( CA 61 S24 o <br /> SUBCONTRACTOR/CONSULTANT e, IL PHONE )4- C- <br /> SUBCONTRACTOR/CONSULTANT ADDRESS `C'"'� CrrY/STATEZP S 6,0,e— 2 <br /> LICENSE >(C-57 - C-61 - D-09 -Other NUMBER 6 6 C O EXPIRATION DATE D S// /ZO I ' <br /> BILUNO PARTY: -OWNER CONTRACTOR - SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:-General Mineral/Coliform Bacteria(4391)-Dibromochloropropane(4392)-Arsenic(4393) <br /> INTENDED USE -DomesticJPrivate - Irrigation/Agricultural = Industrial -Water Quality Monitoring (Soil Sampling/Charactenzation <br /> - Public Water System <br /> I <br /> If ditte/ent!turn O—w Willer System Name Contact Nemo or Phone Number <br /> TYPE OF WORK -New Well -Replacement Well :Well Alteration/Modification - Other <br /> Monitoring Well(s) #of wells =Sal Boring(s) M of bones Geotechnical ___4 of boongs <br /> -Out-Of-Service Well :Out-Of-Service Well Renewal - Cross-Connection Repair <br /> - New Pum -Pump Replacement -Pump Repair -Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method - Mud Rotary :Air Rotary XAuger - Cable Toot :Push Point : Other <br /> Proposed Well Depth �0 it Excavation in diameter - Open Bottom - Gravel Peck/Gravel Size in diameter <br /> - Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter 6 in Thickness'Gauge/ASTM Sched - Steel - Plastic - Stainless Steel _ Other <br /> Grout Seal Depth .�, ; ft fT'Neat Cement(94/b bary'5-10 gal water) = Sand Cement sack mrx.R gal water <br /> = Bentonite(20%solids) -Other <br /> Grout Placement Method - Pumped -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 - Submersible-Turbine - Other HP Pump Set ft Standing Water Level h <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 ACTNE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOU ADVANCE NOTICE REQUIRED FOR NSPECTIONS-PLEASE CALL(209)9573/-1697 /1^ <br /> SIGHED u-!/ I.CA TITLE I't'e-Q� DATE O// I /`,c 2c <br /> YMENT <br /> _.i- _ CE'VED <br /> G 0 3 2020 <br /> QUIN CUNTY <br /> pNMENT L <br /> DEP,4RTINENT <br /> DEPARTMENT USE ONLY <br /> � f <br /> Application Accepted By Date I'O Area `- 7) Employee ID# <br /> Grout Inspection By Date - SPECIAL Well Permit <br /> Pump Inspection By Date _ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth R <br /> COMMENTS It <br /> PE SC Received CheclW Amount jjDtate PermiUInvoice X Well IDItCodesIMo Cash RemittedS rviCe R e <br /> I I <br /> E11043.06 &11.2019 �/oo WELL PUMP PERMIT <br />