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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE-STOCKTON CA 96206-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRESC�I YEAR FROM DATE ISSUED <br /> JOB ADDRESS C �y IV J`-iL"� Cl� }K- �l �yT CITYZP LCt11 <br /> CROSS STREET L Y�C�f )t(��1 T 1 lU7 AP(N'�i '� t 1,�1��1 l_. PARCEL SIZE LAND USE APPLICATIONS ^ o <br /> OWNER NAME / /\i�,4��) 1 t�� l�(�J W L ` PHONE 'C J C, I ( w <br /> OWNER ADDRESS I C,s\ 1�i ,I J \�1�V�C n t' I`� CITY/STATEZP Lc A 1 I TC/ A 9 S 24C <br /> CONTRACTOR in) 1 C� 1 0 1 1 1 1 I n �l PHONEC)1 J t� -�2-7 71 <br /> I <br /> CONTRACTOR ADDRESS C' CITY/STATEZP &n 1 C^ C)J <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP "7 ] <br /> LICENSE I C-57 C7 9 C-61 D-09 C Other NUMBER « - EXPIRATION DATE 1 3 ) +C,� <br /> BILLING PARTY: J OWNER C CONTRACTOR G SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPUNG:J(General Mineral/Coliform Bacteria(4391) 'Dibromochloropropane(4392).:-Arsenic(4393) <br /> INTENDED USE `f.,Domestic/Privete J Irrigation/Agricultural Industrial L Water Quality Monitoring -. Soil Sampling/Charactenzation <br /> C Public Water System <br /> V dIT—M hom Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well AlterationMlodification Other <br /> ( Monitoring Well(s) #of wells F Soil Boring(s) a or benngs Geotechnical a er bonnge <br /> Out-Of-Service Well Out-Of-Service Well Renewal =:Cross-Connection Repair <br /> ew Pump Pump Replacement -Pump Repair _Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method-AMud Rotary -Air Rotary L.Auger Cable Tool ['Push Point . Other <br /> Proposed Well Depth C( ` ft Excavation 12 in diameter Open Bottom ><Gravel Pack/Gravel Size li 4- in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched C� Steel x Plastic l-,Stainless Steel I Other <br /> Grout Seal Depth I C C It ::Neat Cement(94 lb bag;5-l0 gal water) X Sand Cement j(') S sack mixf7 gal water <br /> _Bentonite(10%solids) Other <br /> Grout Placement Method Pumped i!Free Fall I I Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor. Other <br /> `f,Concrete Pedestal_Dimensions:Width 3 ft Length 5 ft Thick in ._Christy Box :Stove Pipe <br /> PUMP fK Submersible i.i Turbine u Other HP---3— Pump Set-_2s,�ft Standing Water Level 1 g L 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 /> ADVANCE NOTICE REQUIRED FOR INSPEC T IT0 '�-PLLEASc1:r,-L(209)9ti3-',169 <br /> \J <br /> SIGNED �Y"�1' I"-��"''� TITLE 'C e •`^C h T DATE <br /> 1 � 1 i <br /> PAGNjE4-1 <br /> R� <br /> g PNoP <br /> NEP `N J J <br /> EPARTMENT USE; ONLY <br /> Application Accepted By f��f Date Area Employee ID# <br /> Grout Inspection By _ Date 162MIL&O ❑ SPECIAL Well Permit <br /> Pump Inspection By 5 E Lr6-4: O Date t l` -f ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Dat Perms Involcett Well 10# <br /> Codes Into B CashRemitted Service Reu t11 <br /> 1 SjAithqN, 7 <br /> EHD41-06 61112019 WELL/PUMP PERMIT <br />