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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 /> 14N1.� <br /> LA <br /> ADDRESS � CITY/ZIP• m <br /> ' D <br /> CROSS STREET . 1 O �� PARCEL SIZ a I '" AND USE APPLICATI'LONN#j# <br /> OWNER NAME ' PHONE /f { 1Q <br /> OWNER ADDRESS CITY/STATE/ZIP fVY"r / <br /> CONTRACTOR PHONE <br /> kbibCONTRACTOR ADDRESS ae CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT n� �n PHONE <br /> SUBCONTRACT R/CONSULTANT ADDRESS I / ATE/ZIP /�) <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE 15 <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: Gene al Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private I rrigation/AgriculturalIndustrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ 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 � <br /> ❑ Out-Of-Service W II 13 Out-Of-Service Well Renewal Ll Cross-Connection Repair (+ Y <br /> Ll New Pum Pum Replacement Ll Pump Repair ❑ Raise Well CasingSCID <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary Auger C Cable Tool i Push Point e Other EUG'gQVIN <br /> ­1111V --Illy <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom LI Gravel Pack/Gravel 7'H MF/1 AiIameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft TMENT <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> L, Bentonite(20%solids) r._7 Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor !:i Other <br /> 11 Concrete Pedestal❑Dimensions:Width ft Len hft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CER IFY THAT 1 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 /> CURRE AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKE S OMPENSATION L <br /> I R ftR QUIRED FO N P - L ASE CALL(209)SIGNED TITLE DATE 6 [ <br /> 4IL I <br /> D AR ENT US O LY <br /> Application Accepted By c ate r! Area Employee ID#_&J V I�-- <br /> Grout Inspection By nn Date SPECIAL Well Permit <br /> Pump Inspection Byivw;�L.L (��an�� 9.111 Date ol ptL WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> CqAes Info j3y, Cash Remitted Service Request# <br /> CA- 12 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />