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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 .s ov.or /ehd EXPIRES 1 YEAR ROM DATE ISSUED <br /> N <br /> JOB ADDRESS CITY/ZIP m <br /> CROSS STREET QVb APN V 277 0,�1 LI PARCEL SIZE `� LANA USE AAPPPLICATION## A <br /> OWNER NAME P ONE % 3�-'Otv�/j�.�.jlti y <br /> OWNER ADDRESS1316? CITY/STATEIZIP� / ! <br /> CONTRACTOR PHONE �Q73 <br /> CONTRACTOR ADDRESS 10•/� CITYISTATE/ZJP � (A f 6D � <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRY-5 <br /> /CONSULTANT ADDRESS _ `I CIT S TEIZIP <br /> LICENSE 7 C-61 D-09 Other NUMBER ExPIRATIONDATE <br /> BILLING PA .OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELLS X <br /> PLING: _General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE X <br /> Domestic/Private 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 Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells G Soil Boring(s) u of bonngs Geotechnical u of bongs <br /> Out-Of-Servic ell D Out-Of-Service Well Renewal D Cross-Connection Repair <br /> New Pump X Pump Replacement D Pump Repair LI Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method - Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter .Open Bottom Gravel Pack/Gravel Size in diameter <br /> - Conductor Casing in diameter / Conductor Casing Depth ft <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 m/x77 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method ;.Pumped . Free Fall - Other Retardant I Accelerator(name) <br /> PEDESTAL Installed By .. Driller - Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Len gt ft Thick in Christy Box - Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTI 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 LAS. <br /> P fN OU NCE NOTICE REQUIRED FOR I/(�'�{%G'�PEE�C,TIIOOONJS-PLEASE CALL(209)953-7697 <br /> SIGNED /l TITLE DATE <br /> EI ENr <br /> VE® <br /> 5 2020 <br /> O AL <br /> MENTUNTy <br /> E ARTIL7ENT <br /> ,DEPARTMENT USE ONLY <br /> HOZ fiC <br /> Application Accepted By �� L� Date � Q Area � / � Employee ID# S K <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By N"i,tn4'!� Dale \I k)I 1S_L-D WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PESC Received Check#1 Amount Date Permit/ Invoice# Well ID# <br /> Codes Info BX Cash RemittedS rvice Re uest# <br /> tl3 I o: � i c <br /> EH0 43-06 6/112019 WELL/PUMP PERMIT <br />