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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. OV.Or /ehdPIKES 1 YEAR FROM DATE ISSUED <br /> rn <br /> JOB ADDRESS CITY/LP —1'jaca5 <br /> CROSS STREET APN 17��0 f V O PARCEL SIZE ' ✓` LANG USE APPLICATIIOON# o <br /> OWNER NAME t�PH�]O.}NE {��/J��/J�►�).']/�(� 1? <br /> OWNER ADDRESS CITY/STATE/ZIP (�I V n (/� /VQJL] <br /> CONTRACTOR `PHONE,90 <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> T' <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACT /CONSULTANT ADDRESS CI T T/ZIP <br /> LICENSE -57 C-61 D-09 Other NUMBER EXPIRATION DATE <br /> BILLING PARTY: L.OWNER ('CONTRACTOR L SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:-'General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)L!Arsenic(4393) <br /> INTENDED USE omestic/Private -,Irrigation/Agricultural _.Industrial Water Quality Monitoring -Soil Sampling/Characterization <br /> Public Water System <br /> If tliBerent 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 !Soil Borings) #of benaga Geotechnical #of borings <br /> Out-Of-Service W I Out-Of-Service Well Renewal Cross-Connection Repair <br /> G New Pum Pum Replacement !<Pump Repair :I Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method i_ Mud Rotary _j Air Rotary a Auger i Cable Tool ❑Push Point ,_ Other <br /> Proposed Well Depth ft Excavation in diameter Ll Open Bottom i Gravel Pack/Gravel Size in diameter <br /> FConductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad J Steel Plastic Stainless Steel r Other <br /> Grout Seat Depth ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method G Pumped Free Fall it Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By c Driller Pump Contractor Other <br /> -1 Concrete Pedestal i_!Dimensions:Width ft Length It Thick in is Christy Box 7 Stove Pipe <br /> PUMP SubmersibleL,Turbine ' Other HP Pump Set ft Standing Water Level ft <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 ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP TION LAWS. <br /> MINI 48 10 R V7A NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-76978 <br /> k+ <br /> SIGNED TITLE / 2 D,�-a DATE �✓ -�-� <br /> T <br /> 1711 <br /> N 0 <br /> c nL <br /> r3- <br /> DEPARTMENT USENLY <br /> i <br /> Application Accepted By Date v7`�"�D Area I �> Employee ID# S <br /> Grout Inspection By Date -J SPECIAL Well Permit <br /> Pump Inspection By Gr c If Cj\e (QLLjj=,%, Date J WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted ervice a uest# <br /> 3$I OSO <br /> EHD 43-00 6/112019 WELL/PUMP PERMIT <br />