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ydun� <br /> 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 / "�y� www.s' Ov.of /ehd 1I EXP/IIRR���/E�/,S 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> U L/1 J ( V/e Iy CITY/ u (/_ " f �Z m <br /> CROSS STREET Frees;eN APN O 966 OOo(3 PARCEL SIZE�''4 q LAND USE APPLICATION# <br /> 1W�� mOWNER NAME � � { npvl � fn G ZIZ JJV <br /> OWNER ADDRESS bb 1 1`� 35� <br /> / / CITYlSTATE IP <br /> CONTRACTOR v ,e�i A u n� S (, P�°NE ag a <br /> CONTRACTOR ADDRESS V l no �l"/ C Y/ TATE ?�' g5-�V <br /> SUBCONTRACTOR/CONSULTANT I 179 PHONE ffm <br /> SUBCONTRACTOR/CONSULTANT ADDRESS IVA CITY/STATE/ZIP Nl r1 <br /> LICENSE _ C-57 -Q(C-61 - D-09 Other NUMBERJ—) (AP V EXPIRATION DATE " ✓ `--o zlo `r <br /> BILLING PARTY: -OWNER CONTRACTOR 1 SUBCONTRACTOR/CONSULTANT �4- <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) = Dibromochloropropane (4392)C Arsenic(4393) <br /> INTENDED USE omestic/Private 1-: 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 b <br /> TYPE OF WORK _ New Well U Replacement Well U Well Alteration/Modification _: Other <br /> - Monitoring Wells) #of wells n Soil Boring(s) I #of borings - Geotechnical #of borings <br /> - Out-Of-Service Well . I' Out-Of-Service Well Renewal -j Cross-Connection Repair <br /> - New Pump C Pump Replac ment X Pump Repair, C Raise Well Casin C° <br /> ELL CONSTRUCTION J 1) Pi /Ow PM peSe <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 '- Gravel Pack/Gravel Size in diameter C <br /> - Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched -j Steel L� Plastic - Stainless Steel U Other r 1 <br /> Grout Seal Depth ft n Neat Cement(94 Ib bag/5-10 gal water) - Sand Cement sack mix/7 gal water <br /> = Bentonite(20%solids) 2 Other <br /> I Grout Placement Method - Pumped n Free Fall n Other Retardant I Accelerator(name) <br /> PEDESTAL Installed By -- Driller C Pump Contractor C Other N <br /> - Concrete Pedestal UDimensions:Width ft L h ft Thick in _ Christy Box U Stove Pipe <br /> PUMP - Submersible- Turbine n Other HP Pump Set ft Standing Water Level ft N <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 COM NS TION LAWS. <br /> MINI M 8 HOUR ADVANCE NOTICE REQUIRED FOf}Iry IM�- P EASE CALL (209)3 7697 <br /> SIGNED TITLE �(� jl1 �f! <br /> DATE <br /> 54tk I I I I 1 1 1 1 1 1 1 1 1 1 I I i <br /> DEPARTMENT USE ONLY q <br /> Application Accepted By Date 71dl onOaO Area / / 1 Employee ID# Fk <br /> Grout Inspection By Date t 0 SPECIAL Well Permit <br /> Pump Inspection By Date t( VII I 1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS _ <br /> PE SC Received heck Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Request# <br /> 438d o50 77 <br /> EFID 43-06 6/11/2019 WELL/PUMP PERMIT <br />