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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sinov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> JOB ADDRESS CIN/ZIP m <br /> CROSS STREET A N O ( PARCEL SIZE ND USE APPLICATION# S <br /> OWNER NAME ^,PPHHONNE�,'y-)'_) <br /> OWNER ADDRESS / 4akI7Y/STATE/ZIP C/%��"7•,1L—U^V T�{9J vL/^,� <br /> CONTRACTOR '2[ <br /> PHONE <br /> CONTRACTOR ADDRESS O[-I O(L/ ` I W/�' LCU CITYISTATE/Z1P <br /> SU13CONTRACTORICONSULTANT ^ /4 PHONE <br /> SUBCONTRAC►f/7pR/CONSULTANTADDRESS CI/J/STATEIZIP <br /> LICENSE NC-57 C-61 D-09 Other NUMBER EXPIRATION DATE <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial "Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water Syst <br /> It different from Omer Water System Name Contact Name or Phone Number <br /> TYPE OF WORK _New Well 11 Replacement Well r.Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells C Soil Boring(s) a of bo nes Geotechnical of rings Q <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair EP 12 qo <br /> New Pump Limp Replacement _ Pump Repair -Raise Well Casing $.q C <br /> WELL CONSTRUCTION H EAy�"W /N�O(1 <br /> Drilling Method Mud Rotary G Air Rotary -i Auger Cable Tool _Push Point - Other ALN)P MENMr <br /> Proposed Well Depth It Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diamet <br /> .Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched _Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bagl5-10 gal water) :Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method - Pumped Free Fall Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By -Driller :_Pump Contractor - Other <br /> Concrete Pedestal..Dimensions:Width ft Leng hft Thick in L Christy Box .]Stove Pipe <br /> . <br /> PUMP Submersible-Turbine Other HP Pump Set ft Standing Water Level It <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 /> CURRE AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORK S COMPENSATIO �SCneO <br /> MIIA 8 I ICE REQUIRED F NSPE IONS-PLEASE CALL(209), -7 SIGNED r111 <br /> TITLE DATE <br /> VF <br /> TM NT E NLY <br /> Application Accepted By Date Area Employee ID <br /> #4&� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By x S (�Lt. f5ifjt P.e-"V1 Date Z T7161 1cl WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received heck# Amount Permit' <br /> o s Info B emitted Date Service Request# Invoice# Well ID# <br /> EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />