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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 wn.sjgov.orqlehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> TN, <br /> JOB ADDRESS r D v]� I V 15 toyl K4 CITY/ZIP ` l )-T- <br /> CROSS <br /> CROSS STREET ffi1 APN 01:Y7LOW OC.� PARC,EL SIZE � LAND USE <br /> t�A/PPLICATION# z <br /> �` U J 14 PHONE <br /> OWNER NAME / I J <br /> "' " I .7 U CITY STAT/E1LIP L <br /> OWNER ADDRESS �,{ / <br /> CONTRACTOR / -^" l/ IVI' P/ li ` A PHONE <br /> CONTRACTOR ADDRESS I �" r CITY/STAT 14 411 C4Cl ✓ <br /> SUBCONTRACTOR/CONSULTANT IIV PH E <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP r <br /> LICENSE _ C-57 XC-61 _ D-09 Other 01-t NUMBERZ� `� " EXPIRATION DATP 1 - V <br /> BILLING PARTY: OWNER ONTRACTOR -1 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: ElGeneral Mineral/Coliform Bacteria(4391)= Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private D 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 Other <br /> Monitoring Well(s) #of wells n Soil Boring(s) #of borings - Geotechnical #of borings <br /> Out-Of-Servi e Well Out-Of-Service Well Renewal _, Cross-Connection Repair <br /> = New Pum Pump Replacement ❑ Pump Repair r_ Raise Well Casing <br /> WELL CONSTRUCTION T <br /> Drilling Method _ Mud Rotary U Air Rotary L Auger _ Cable Tool L Push Point _ Other <br /> Proposed Well Depth ft Excavation in diameter ! 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 Schad J Steel U Plastic _ Stainless Steel U Other <br /> Grout Seal Depth ft F1 Neat Cement(94 lb bag/5-10 gal water) 7 Sand Cement sack mix17 gal water '1 <br /> - Bentonite(20%solids) 7, Other <br /> Grout Placement Method - Pumped n Free Fall n Other r1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By -- Driller D Pump Contractor C Other " <br /> _ Concrete Pedestal❑Dimensions:Width ft Leth ft Thick in _ Christy Box U Stove Pipe <br /> PUMP 71 Submersible- Turbine rl 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 /> CURRENTAN ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKER ENSATION LAWS. <br /> MI UM 48 HOUR ADVANCE TICE REQUIR D FOF,INSPECTIONS//- PLEASE CALL (209) 5 �6 7 <br /> SIG - ITLE � I� �,,,P ! rte, V DATE ✓ <br /> 00, <br /> V <br /> ask <br /> E IR N <br /> E T � <br /> N <br /> / DEPARTMENT USE ONLY p <br /> Application Accepted By � �L� Date_7/_/%L,40120 Area S y<� Employee ID#_t� FI` <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By X�t.�nV ,L� (vLr,,�„v Date 1J1tiC I I WAIVER Received <br /> Soil Boring Inspection By _ Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC ReceivedChec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> 3f o so 00 <br /> EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />