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tc , <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 'I YEAR FROM DATE ISSUED <br /> JOB ADDRESS C� CITY/ZIP l ��i m <br /> JJ 7/u oj1 � 0 <br /> CROSS STREET L to C- (/!�� APN �/ 0 <br /> PARCEL SIZE LAND USE APPLICATION# 0 <br /> X <br /> yy _ '+� m <br /> OWNER NAME j PHONE /Q d 702 ui <br /> OWNER ADDRESS /1 14, CITY/STATE/ZIP LY,J) , <br /> CONTRACTOR A&//C�l ( ��'Lc1i� lJ/ /L L� lI�—; PHONE <br /> /' �f���'/7► ��' <br /> CONTRACTOR ADDRESS 17� CITY/STATE/ZIP "`—ONQ <br /> / SSUBCONTRACTOR/CONSULTANT <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE >--rC-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER, 77.38_y EXPIRATION DATE G LL <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4390 1 <br /> INTENDED USE n Domestic/Private 4rrigation/Agricultural C Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Charac erization <br /> ❑ Public Water System APR <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 E0,.QLJIN Cot <br /> 11Monitoring Well(s) #of wells [I Soil Boring #of borings AL7'4's) ❑ Geotechnical TTAL <br /> MENT <br /> C Out-Of-Service Well Li Out-Of-Service Well Renewal F1 Cross-Connection Repair <br /> New Pum ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary - Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth t ft Excavation y in diameter ❑ Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑ Conduct6 Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 0 in Thickness/Gauge/ASTM Sched2 00 ❑ Steel Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth C t) ft ❑ Neat Cement(94 lb bag/5-10 gal water) 21c'Sand Cement /CJ- �' sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method-"r Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By PLeOriller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal Ll Dimensions:Width ft Length ft Thick in CI Christy Box ❑ Stove Pipe <br /> PUMP )cSubmersible❑ Turbine ❑ Other HP Pump Set l`S 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�-77697 <br /> SIGNED ,�[/ TITLE Ore c/iLr4� 1 DATE 'I/- / — LJ <br /> ~ � S <br /> 71 <br /> A <br /> EN VI N E T L HE-Al HE-AlT ^ <br /> tI idl <br /> DEPARTMENT USE ONLY <br /> Application Accepted By LL— Date qe Zo ZO Area A C Employee ID# SK <br /> Grout Inspection By 1 Date C SPECIAL Well Permit <br /> Pump Inspection By itAA;5u �4reh: y Date `tVW1911 ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cas Remitted Service Request# <br /> --36q )80 y,�p t� b- 1� C 1. l <br /> Seo Opo S2 AA-1-U W 0 L 0-'1 -+ <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />