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1 <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 www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITYIZIP <'e d h_ m <br /> D <br /> CROSS STREET { _AP//N -GW J� PARCEL SIZE LAND USE <br /> APPLICATION <br /> #,/r <br /> _ �/ /l/ 1v L i/(/ / / v <br /> OWNER NAME PHONE ui <br /> OWNER ADDRESS _ _�_ %V' _ CITY/STATEIZIP <br /> CONTRACTOR Q.J� �li Z i iL q, _ �PHOJNE)2; L"„J/��` <br /> CONTRACTOR ADDRESS CITY/STATEIZIP <br /> SUBCONTRACTOR/CONSULTANT "4 -ItJ- /(/ nSir ��{� �/=�7✓�9t <br /> `�'�'I/ PHONE 3 ,7 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP �r <br /> LICENSE _-.<�-57 ] C-61 ❑ D-09 iJ Other NUMBER 7 Z.3 f EXPIRATION DATE_��i/ <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 U Industrial ❑ Water Quality Monitoring t I Soil Sampling/Characterization <br /> I I Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK >Vew Well fl Replacement Well 1-1 Well Alteration/Modification I1 Other <br /> i I Monitoring Wells) #of wells r I Soil Boring(s) #o1 borings 11 Geotechnical_ #of borings <br /> Out-Of-Service Well i I Out-Of-Service Well Renewal t I Cross-Connection Repair <br /> ]il-eew Punlp 1=1 Pump Replacement i7 Pump Repair _ 1.1 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ;I Mud Rotary [2 Air Rotary P Auger!/U Cable To F1 Push Point Other <br /> Proposed Well Depth �'� ft Excavation f/ in diameter I I Open Bottom ">e Gravel Pack/Gravel Size�� n diameter <br /> CI CondUC Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched'L-n'V n Steel >k/Plastic I Stainless Steel I Other <br /> Grout Seal Depth7-Q® / ft I I Neat Cement(941b bagl5-10 gal water) Sand Cement /0-3 sack mix/7 gal water <br /> i1 Bentonite(20%solids) FI Other <br /> Grout Placement Method,, Umped ❑ Free Fall U Other H Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor FI Other <br /> I I Concrete Pedestal IIDimensions:Width it Length fl Thick _in U Christy Box U Stove Pipe <br /> PUMP —),,tSt bmersiblel i Turbine Other HP— —Pump Setft Standing Water Level ft <br /> I HEREBY CERTIFY THAI" I HAVE PREPARED THIS APPLICATION AND THAI' 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 18 HOUR AE)VANCE NOTICE REQUIRED FOR/ <br /> INSPECTIONS -PLEASE CALL(209) 953-7697/ <br /> SIGNED - TITLE DATE <br /> 1 31-1 <br /> ILI <br /> D P RTMENT U /E/ N L Y <br /> AppNcation Accepted By _ _. Date v AreaEmployee ID# ' <br /> Grout Inspection By Date !.v Gv SPECIAL Well Permit <br /> g <br /> Pump Inspection By4�0 (pnt4 DateS(1S�`l4 _ WAIVER Received <br /> Soil Boring Inspection By _ _ Date Constructed Well Depth_ _ft <br /> COMMENTS <br /> PE SC Received C eck#/ Amount Permit/ <br /> Codes Info B Cash mitted Date Service Request# Invoice# WeIIID# <br /> -12 2•lel 0 +-12 <br /> (c� = D Z <br /> -- o • 2. 01 900 2 <br /> EHD43-0G 6/'11/2019 WELL/PUMP PERMIT <br />