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c • <br /> T <br /> 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 2 (� WWW.s ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED 0 5 7 ( 1 (� CITY/ZIP m <br /> JOB ADDRESS -�S CQ l�^ J ` � ! �✓ <br /> CROSS STREET CoLiN b-e l APN (� 3�Q PARCEL SIZE! -SR GLAND USE(APPLICATION# S <br /> OWNERNAME f! I ► MAr`7 GrrL4,4rcL'5 PHONE <br /> OWNER ADDRESS `�U Z Sac.kS6 �`l./ - CITY/STATE/ZIP E Cct 10 h `-��Z <br /> CONTRACTOR M GCs YennLl[l• D{'`�\ l�J ``r h,e. PHONE .SzZ` Z CI GJ`�Q <br /> CONTRACTOR ADDRESS I I_I A Cb,erS CITY/STATE/ZIP Mo -P S�O C5 S 3S� <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE 'gC-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE Y-3 6 iZ l <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <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 /> 1 Public Water System <br /> If different 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 Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal CI Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTI <br /> Drilling Method ❑ ud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth X60 ft Excavation 12, in diameter ❑ Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑ Conduct Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 9 UO LlSteel Plastic ❑ Stainless Steel i.I Other <br /> Grout Seal Depth_20 y ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> XBenton to(20%solids) ❑ Other <br /> Grout Placement Method umped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑I 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 /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 953-7697 <br /> SIGNED y ITVJ.EI &Akl''e- DATE �9 <br /> Al <br /> I< <br /> VEA <br /> v <br /> ;Ty <br /> V,R0Nhl N E ANT <br /> 6 <br /> E /ARTMENT U E ONLY5;7 / <br /> A_&� <br /> Application Accepted By I,,�n Date Area--L � Employee ID <br /> Grout Inspection By )�lf-+n+� Date 1 SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Ins ection By Date Constrl,106AWell Depth ft <br /> COMM NTS �/� <br /> / , <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> CoderL fo B Cash Remitted ,n Service Request# <br /> c (� <br /> OR— ' 3—j4- 10 1 'AS '70V og '1101 d2 <br /> v c� y49 0030ttlZ2 <br /> EHD 43-06 6/11/2019 <br /> WELL/PUMP PERMIT <br />