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tra <br /> WELLIPUMP 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.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS v Q l�V -top CITY/ZIP � � m <br /> _ D <br /> CROSS STREET I IC�n Pd APN d y5 12 <br /> D d� PARCEL SIZE �� LAND USE APPLICATION# A <br /> m <br /> t l l l G e i PHO,�IE N <br /> OWNER NAME C <br /> OWNER ADDRESS U�(4 v j/ �v CITY/ AT <br /> CONTRACTOR <br /> 1-• V �. J PHONE <br /> CONTRACTOR ADDRESS 0 CITY/STAT�b <br /> SUBCONTRACTOR/CONSULTANT PHONE 1 S <br /> 14 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATEIP / /� Y� <br /> LICENSE _ C-57 �'LJ C-61 _ D-09 LI Othe 1 NUMBER2_7 (nAT(A/Z! <br /> E`•' f S() EXPIRATION DATE f/V \ <br /> BILLING PARTY: OWNER CONTRACTOR -1 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WEL MPLIND: ❑General Mineral/Coliform Bacteria (4391) - Dibromochloropropane(4392)❑ Arsenic(4393) --�- <br /> INTENDED USE _ Domestic/Private u Irrigation/Agricultural _ Industrial _ 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 u Replacement Well a Well Alteration/Modification _j Other <br /> - Monitoring Well(s) #of wells n Soil Boring(s) #of borings Geotechnical of borings <br /> _ Out-Of-Servic Well L Out-Of-Service Well Renewal a Cross-Connection Repair <br /> - New Pum um Replacement ❑ Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method _ Mud Rotary L Air Rotary Li Auger _ Cable Tool L Push Point Other <br /> Proposed Well Depth ft Excavation in diameter L Open Bottom L Gravel Pack/Gravel Size in diameter <br /> _ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched J Steel ❑ Plastic _ Stainless Steel L Other 1 <br /> Grout Seal Depth ft n Neat Cement(94 lb bag/5-10 gal water) F1 Sand Cement sack mix/7 gal water <br /> - Bentonite(20%solids) :1 Other <br /> Grout Placement Method - Pumped n Free Fall n Other n Retardant I Accelerator(name) <br /> PEDESTAL Installed By - Driller ❑ Pump Contractor C Other v 1 <br /> _ Concrete Pedestal UDimensions:Width ft Le gth ft Thick in _ Christy Box u Stove Pipe <br /> PUMP Submersible- Turbine n 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 C_ <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 COM NSATION LAWS. <br /> I I M 48 MO VA E N E QUlRED FO SPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED ITL Ev � (' O /T� DATE <br /> 11 v <br /> C <br /> S EN�t G <br /> E1pA k, N -- <br /> Hep'l- DEPARTMENT SE ONLY /a <br /> ��/` z— Date 13 2CO Area L/ Employee ID# �� <br /> Application Accepted By <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By :*a �.s.�. Date ���S�1A1� ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received S�pAmount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service R%quest# <br /> 9391 oso �7 'L 1 � <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />