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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 www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ln <br /> JOB ADDRESS CITY/ZIP m <br /> Q D <br /> CROSS STREET �f n c h f C�fir` (z�ad ��`�� APN ��O U PARCEL SIZELAND USE APPLICATION# O <br /> NcrF1, I<enne z <br /> m <br /> OWNER NAMECons+ellc 'it n 13r�.n��S )TIC: PHONE I (7CR)-36S-�t3� ui <br /> OWNER ADDRESS L L^ G(n}('way tZaaA Eksl CITY/STATE/ZIP NCA <br /> CONTRACTOR i•fithPr Se r V i,�(?S 4 LLC PHONE <br /> CONTRACTOR ADDRESS liq Oeme�(r 5�reeA CITY/STATE/ZIP P_&s+ Peslb Al &-4(,A Ct`I�ib� <br /> SUBCONTRACTOR/CONSULTANT 51H4P Cec}�CJIYIiCa) CtnSv��GynF51 iFaL: PHONE 1'(SID)' 77-33 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS L-11t 8 L131-1k S}�''i} CITY/STATE/ZIP t'icO-_Jar7A ) CA 10 C11 <br /> LICENSE x C-57 C-61 _ D-09 _ Other NUMBER I t It Lt9,l 5 EXPIRATION DATE Septi'-, -3C t ZC ZC <br /> BILLING PARTY: OWNER _CONTRACTOR X SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) 1 Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE _ Domestic/Private l_ Irrigation/Agricultural _ Industrial Water Quality Monitoring X Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well _ Replacement Well -: Well Alteration/Modification _ Other <br /> Monitoring Well(s) #of wells X Soil Boring(s) 3 #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method X Mud Rotary _ Air Rotary _ Auger _. Cable Tool _ Push Point Other <br /> Proposed Well Depth 5C 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 Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth S D ft Neat Cement(94 Ib bag/5-10 gal water) _ Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method 'y 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 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 7HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209)953-7697 <br /> SIGNED /C ull �iL!f,"t- IVc'rh�n �l W AQ)jc, TITLE f7i,a3tc�ineer DATE A�4 2-C Zi'-' <br /> J <br /> 202 L_ <br /> AA I <br /> IS J <br /> VR <br /> TDEPARTMENT USE ONLY tARTMENT <br /> Application Accepted By �/� LZ- Date a- do_do Area Aq Employee ID#�� <br /> Grout Inspection By Date C SPECIAL Well Permit <br /> Pump Inspection By Date a WAIVER Received <br /> Soil Boring Inspection By Date�)��1 I Zjf�� Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted j ervice Re nest# <br /> 37d 1 s� 7C-� <br /> EHD 43-06 6/1'/2019 WELL/PUMP PERMIT <br />