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I��Zt u <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH-DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT www.Ngov.org/ehd EXPIRES IYEAR FROM DATE ISSUED <br /> 21 /� / e-, r, <br /> JOB ADDRESS j r m t c � U O CITY/ZIP / l N V m <br /> CROSS STREET '✓ � Fe r r� 5,�3g00 y0 qq D <br /> U, � APN � •- 6 PARCEL SIZE USE APPLICATION# o <br /> tv7 ��G� M L1-�� �� N <br /> OWNER NAME <br /> OWNER ADDRESS ✓"'" v -1 CITY/STA 21P kj�l <br /> CONTRACTOR G r�nn /u " PHON )'o �/ ~ <br /> CONTRACTOR ADDRESS C I CITY/STATE/ZI J <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS • 1 CITY/STA�T/E�//ZII,P <br /> LICENSE C-57 ✓L4 C-61 D-09 D Other v I NUMBEI� �IJG W O EXPIRATION DATE <br /> BILLING PARTY: OWNER CONTRACTOR -1 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria(4391) = Dibromochloropropane(4392)❑ Arsenic(4393) <br /> INTENDED USE Domestic/Private u Irrigation/Agricultural _ Industrial _ Water Quality Monitoring _ 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 L Replacement Well U Well Alteration/Modification J Other <br /> - Monitoring Well(s) #of wells (1 Soil Boring(s) #of borings - Geotechip -Nlrings <br /> _ Out-Of-Servic 5011 U Out-Of-Service Well Renewal U Cross-Connection Repair vto s <br /> - New Pump Pump Replacement ❑ Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION ?020 <br /> Drilling Method _ Mud Rotary U Air Rotary U Auger _ Cable Tool L Push Point Other SAN j U <br /> Proposed Well Depth ft Excavation in diameter J t/�d? <br /> Open Bottom L GraveWin diameter <br /> _ Conductor Casing in diameter / Conductor Casing Depth ft 0EPARTh1ENT <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched J Steel u Plastic _ Stainless Steel U Other <br /> Grout Seal Depth ft n Neat Cement(94 lb bag/5-90 gal water) n Sand Cement to sack mix/7 gal water <br /> - Bentonite(20%solids) -1 Other <br /> Grout Placement Method - Pumped Tl Free Fall n Other Fi Retardant/Accelerator(name) <br /> PEDESTAL Installed By - Driller ❑ Pump Contractor C Other `fl <br /> Concrete Pedestal UDimensions;Width ft Le h ft Thic in _ Christy Box U Stove Pipe W <br /> C <br /> PUMP - Submersible- Turbine n Other HP Pump Set ft Standing Water Level I U 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 /> 4 <br /> J!IA S HO ADV NC NC?T E REQUIRE FO �S�P�ErIC/TI�ON�S/-P^L�EASE CALL (209) X53-7 9? <br /> SIGNED ITLE _'V/L I t 1.� I 1 !tiL DATE <br /> i <br /> I I le tt <br /> DEPARTMENT USE ONLY <br /> 7� <br /> Application Accepted By Date d aadv Area Employee ID# OFR <br /> Grout Inspection By Date C SPECIAL Well Permit <br /> � 1 <br /> Pump Inspection By f Jl nt�5(0 (�gAlt.c t Date 91(i no u P WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS_ <br /> PE SC Received hec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B s Remitted Servic Re st# <br /> 9391 o X77 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />