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N A / 9.5'174' <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)46"420 <br /> NON-REFUNDABLE PERMIT %VWW.Sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> c SZo$ <br /> JOB ADDRESS n3.z6,3 �Efq f/'��,,�(�Q,ro eQ c0 CnY/ZIP J'�k-t5°N bmyyy <br /> CROSS STREET�F-t�/fP11 r�u �l.rV'.r G["'�AP /2070 1 D PARCEL SIZE 14- LANo USE APPLICATION# A <br /> OWNER NAME —TLAA IAC' I,tPIHONE / 7 / <br /> OWNER ADDRESS ll�W Westbrook 1.01DO( . �QN..'LW� Cm/STATE21P V"Q.St 7,{A•Q }�' DO1 <br /> pi <br /> CONTRACTOR h�'Qif'S0�((1 PHONE A'1���1� �/7�^7- 37'1 <br /> CONTRACTOR ADDRESS ]O Z I' s/ l al/ wA'L1 CITYISTATE/ZIP �OQI ( (-A / /EL� <br /> SUBCONTRACTORICONSULTANT N/ A /l,,/'1 Q ITY PHONE,( �1/A N/A <br /> SUBCONTRACTORICONSULTANT ADDRESS NC /STATErLP IS C ]� <br /> LICENSE )(C-57 C-61 D-09 Other NUMBER 66 O C IfEXPIRATION DATE —3/~" 24 <br /> BILLING PARTY: XOWNER CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)�j Dibromochloropropane(4392)_Arsenic(4393) <br /> INTENDED USE Domestic/Private - Irrigation/Agricultural .Industrial :Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different Gam Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well I Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells (Soil Bodng(s) 0 bon"ve (Geotechnical <br /> Out-Of-Service Well -I Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement i Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary X Auger Cable Tool Push Point Other <br /> Proposed Well Depth 10^;�1119 ft Excavation_b,r in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Wall Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic - Stainless Steel Other <br /> Grout Seal Depth If X Neat Cement(94 Ib bagi5-10 gal water) Sand Cement sack mix77 gal water <br /> Bentonite(20%solids) 7 Other <br /> Grout Placement Method _Pumped Free Fell X Other i P, 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 ::I Other HP Pump Set ft Standing Water Level fl <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 /> MIN MMUy 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> lw. 2� �pb to?O <br /> SIGNED 1w/ � TITLE r1 DATE <br /> / i - - <br /> 1 140 <br /> 0 <br /> D PA*TMENT U NLY <br /> Application Accepted By JIL Date Area L l ( Employee ID# <br /> Grout Inspection By Date _ SPECIAL Well Permit <br /> Pump Inspection By Dale WAIVER Received <br /> Soil Boring Inspection By _Date <br /> J <br /> COMMENTS <br /> Pt_ o.: Received O-kti-' AmountDate Permit/ Invoice# Wall IDS <br /> Codes Info B 1i Remitted Service R.,,..t# <br /> 7 U Z � 3Z w <br /> EH04b 61112019 WELL PUMP PERMIT <br />