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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-REFUNDAB PERMIT www.sjgov.org/ehd EXPIRES YEAR FROM DATE ISSUED <br /> rA <br /> JOB ADDRESS CITY/ZIP ( I <br /> m <br /> r D <br /> CROSS STREETh&A APN O ZI PARCEL SIZE / _LAND USE A�P(PLLIICATION# <br /> OWNER NAME I I •� LJ O PHONE a(J q -b-la lY-1 ) 0� t�'n <br /> AA <br /> OWNER ADDRESS �QY) :tclnnun F02( CITY/STATE/ZIP <br /> CONTRACTOR "MUM <br /> CONTRACTOR ADDRES.Zgw `( A�M.IiDX CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT '�J� PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS ITY/STATE/ZIP <br /> 46 <br /> C&to <br /> LICENSE XC-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br /> BILLING PARTY: G OWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: G General Mineral/Coliform Bacteria (4391) "I 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 from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> ❑ Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service lell 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> ❑ New Pump Pump Replacement ❑ Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary ❑ Auger 0 Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched LiSteel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br /> 0 Bentonite(20%solids) ❑ Other <br /> Grout Placement Method 0 Pumped 0 Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length It 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 /> WORK E COMPENSATION LAWS. <br /> I DVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 9.53-7697 <br /> SIGNED TITLE DATE (J�/ <br /> till <br /> Vy WENT <br /> F - <br /> H. <br /> EA_Th D PAT E T <br /> DE ARTMENT USE ONLY <br /> Application Accepted By Date / W Area l Employee ID# L" c fie-£ <br /> Grout Inspection By Date Cyq ❑ SPECIAL Well Permit <br /> Pump Inspection By ` 1. Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Da Permit/ Invoice# Well ID# <br /> Codes Info Ca Remitted Service Request# <br /> .33G2A PP I <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />