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t 'a <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.sjqov.Or lehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> ✓ rn <br /> JOB ADDRESSN ..��,,rr��,, CITY/ZIP 1G m <br /> /G�� 7, APN,05/-70 ' V? — D <br /> CROSS STREET'/V", <br /> �// PARCEL SIZE LAND USEA/PPLI�C(ATION/#U,� Q p <br /> lin <br /> OWNER NAME / / k/�r PHONE <br /> v N <br /> OWNER ADDRESS IT/ { <br /> CONTRACTOR //QrJ� I/� f PHONE-93- <br /> HONE3- i/�'n/�7 2 J <br /> CONTRACTOR ADDRESS �7c CITY/STATE/ZIP er-IJl/ <br /> SUBCONTRACTOR/CONSULTANT !��` (!/�+.�� �L / PHONE 3 27 3l�J <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 2CITY/STATE/ZIP <br /> LICENSE ��-57 0 C-61 ❑ D-09 ❑ Other NUMBER) 7? EXPIRATION DATE_ Z/ <br /> BILLING PARTY: OWNER ' CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:i General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> yy <br /> ��If��different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK >qr ew Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> 0 Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings ❑ Geotechnical_ #of borings <br /> CI Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ew Pump 0 Pump Replacement ❑ PUrnp Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ MudRotary ❑ Air Rotary ❑ Auger ❑ Cable Tool 11 Push Point El Other <br /> Proposed Well Depth-6F0 ft Excavation `/ in diameter ❑ Open Bottom '5W Gravel Pack/Gravel Size in diameter <br /> ❑ ConducCasing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched7_0 0 n Steel >ePlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ® / ft 0 Neat Cement(94/b bag/5-10 gal water) Sand Cement 1d'3 sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method,--�I umped 0 Free Fall 0 Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 0 Pump Contractor ,❑ Other <br /> ❑ Concrete Pedestal ODImensions:Width_�_ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> [PUMP kSubmersible❑ Turbine ❑ Other HP �Z_ 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 COMPENSATION LAWS. <br /> MINIMUM 18 AJYVANCE NOTICE REQUIRED FOR//INSPECTIONS-PLEASE CALL(209) 953-7697 <br /> SIGNED_ / ~ TITLE DATE <br /> n <br /> I <br /> D P RTMENT U E NLY <br /> Application Accepted By Date l Area Employee ID#� <br /> Grout Inspection By Date !iv(,V SPECIAL Well Permit <br /> Pump Inspection Byh�c��tle✓T� L Dates('IA`L4 WAIVER Received <br /> Soil Boring Inspection By _ Date Constructed Well Depth 4_1 ft <br /> COMMENTS <br /> PE SC Received eck#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Initted Service Re nest# <br /> 0 H2 <br /> o D Z <br /> o 12 . 2.101 P00 2 _ <br /> ZIN <br /> �L <br /> EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />