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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 >j A 6www.s' ov.or /ehd r EXPIRES 1 DEAR FROM DATE ISSUED <br /> JOB ADDRESS ` �U 1� U��1� CITY/ZP y�✓ � m <br /> 9 / / y <br /> CROSS S /TREET Y;e forAve- APN� OZ O�9 /�I I O 1b PARCEL SIZE!73•Iq LAND USE APPLICATION <br /> rn <br /> OWNER NAME %\�' � PHONE �� d <br /> OWNER ADDRESS (® VI' 1/9-v I� Ird CITY/STATE/ZIP ! Y .O,3, <br /> cv �� � S � 5C GG �J, <br /> CONTRACTOR L <br /> � -14 <br /> �--- I {�PHONE <br /> CONTRACTOR ADDRESSIq <br /> `!0C4 '� CITY/STATEIzIP}�" `�'! i �✓ -�` <br /> SUBCONTRACTOR/CONSULTANT PHONE f/� <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATEIZI <br /> 1LICENSE C-57 C-61 D-09 U OthNUMBERO" ., <br /> BILLING PARTY: —OWNER CONTRACTOR. 1 SUBCONTRACTOR/CONSULTANT <br /> i <br /> DOMEST1aC WELLS PILING:0 General Mineral/Coliform Bacteria(4391) = Dibromochloropropane(4392)D Arsenic(4383) <br /> INTENDED USE Domestic/Private U Irrigation/Agricultural _ Industrial _ Water QualityMonitoring ; 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 U Replacement Well U Well Alteration/Modification J Other PA i <br /> Monitoring Well(s) #of wells n Soil Boring #of burins s) 9 - Geotecq� rrngs <br /> _ <br /> Out-Of Se a Well U Out-Of-Service Well Renewal U Cross-Connection Repair �VCD <br /> = New Pum Pum Replacement 0 Pump Repair C Raise Well CasingC VN <br /> WELL CONSTRUCTION /y r <br /> Drilling Method _ Mud Rotary U Air Rotary u Auger _ Cable Tool L Push Point _ Other `Atv j,, 20?O <br /> Proposed Well Depth ft Excavation in diameter J Open Bottom L Graw�r�� ,-- in diameter <br /> _ Conductor Casing in diameter / Conductor Casing Depth ft �FPARTTME� Iu <br /> Well Casing Diameter_ in' Thickness/Gauge/ASTM Sched J.Steel U Plastic _ Stainless Steel U OML7- <br /> Grout Seal Depth ft n Neat Cement(94 Ib bag/5-10 gel water) n Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) 7 Other <br /> Grout Placement Method - Pumped n Free Fall n Other n Retardant/Accelerator(name) <br /> PEDESTAL Installed By = Driller 0 Pump Contractor C Other <br /> -'Concrete Pedestal uDimensions:Width ft Length it Thick in _ Christy Box U Stove Pipe a►�1 <br /> r �p <br /> PUMP - Submersible- Turbine n 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 I AM IN COMPLIANCE-WITH ALL <br /> WORKERS COMV§NSATION LAWS. <br /> MINI 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209)953-7697 <br /> SIGNED. TITLE �- ® L � DATE �� ?/ <br /> 4 1-1 <Aff <br /> --------------- <br /> DEPARTMENT USE ONLY <br /> Application Accepted By L L Date 7 Area Employee ID# <br /> Grout Inspection By Date 0 SPECIAL Well Permit <br /> Pump Inspection By t�tqb L� 4y�;� •� Date gI A)(V-t- I.1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> 381 050 7 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />