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WELUPUMP PERMIT <br /> 9 <br /> M AL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> 0. A de-- <br /> www'sjgov.org/ehd EXPIRES 1 V) �y/ <br /> YEAR FROM DATE ISSUED <br /> CITY/Zip rY -l.{^L ('S I <br /> SCCROSS STREET APN 103)-4010 PARCEL SUS+'-)' LAND USE APPLICATION# S <br /> OWNER NAME CA PHONE "' ` W - DU I !! <br /> OWNER ADDRESS CITY/STATEMP j Il <br /> CONTRACTOR rr 3 L I PHONE ,�LZ• l tL�'�•U t Vq <br /> t/n� <br /> CONTRACTOR ADDRESS �V ` c� ,)c. I—/1�7 VI CITY/STATE/LP R I yef bwn KOO It 3 a7 <br /> SUBCONTRACTOR/CONSULTANT YT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS 'CITY/STATEIZIP <br /> LICENSE x C-57 C-61 D-09 Other NUMBER EXPIRATION DATE <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING::I General Mineral/Coliform Bacteria(4391)Ci Dibromochloropropane(4392)i I Arsenic(4393) <br /> INTENDED USE Y,DomesfidPrivate Irrigation/Agricultural _,Industrial Water Quality Monitoring i-Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK �,y New Well I I Replacement Well I Well Alteration/Modification I_I Other <br /> /Monitoring Well(s) #of wells Soil Boring(s) #of bor ngs Geotechnical a of bo ngs <br /> Out-Of-Service Well Out-Of-Service Well Renewal ICross-Connection Repair <br /> New Pum i Pump Replacement I Pump Repair -Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method.)CMud Rro�ta�ry Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth of 7�U ft Excavation I •� in diameter r1 Open Bottom iI Gravel Pack/Gravel Size in diameter <br /> Conductpr Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter �j n Thickness/Gauge/ASTM Sched S�2- 1-1Steel )(Plastic a Stainless Steel a Other <br /> Grout Seal Depth�N ft i I Neat Cement(94 Ib bag/r10 gal water) ❑Sand Cement sack mix/7 gal water <br /> (Bentonite(20%solids) Other <br /> Grout Placement Method XPumped i;Free Fall 5 Other ri Retardant/Accelerator(name) <br /> PEDESTAL Installed By 1 I Driller n Pump Contractor CI Other <br /> I Concrete Pedestal uDimensions:Width ft Length ft Thick in I Christy Box 1!Stove Pipe <br /> PUMP I Submersible Li Turbine 1: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 /> MINIM 8 VANCE NOTICE REQUIRED FOR INSPEfCTI S-'R{1'�EA E CALL(209)9 3 76 <br /> SIGNED TITLE � � 1� DATE <br /> AYNiENT <br /> ECEIVE® <br /> UG 15 2019 <br /> A(A SAI JOAQUIN COUNTY <br /> NVIRONMENTAL <br /> IFE LTH DEPARTMENT <br /> DflPARTMENTE ONLY <br /> Application Accepted By Date AreaYE. PECIAL <br /> mployee ID# <br /> Grout Inspection By DateL_h Well Permit <br /> Pump Inspection By Date EWAIVER Received <br /> Soil Boring In ection By Date Constructed Well Dep ft <br /> COMMENTS r At -r <br /> til -e <br /> PE SC Received Check#/ Am unt Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Re uest# <br /> ( <br />