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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 www.sjgov.org/ehd/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> L%XAMC <br /> � Ln ADDRESS 6a� CITY/ZIP 1 01_ M <br /> m <br /> CROSS STREETAPN OO Sao ✓ PARCEL SIZE ��vV LAND USE APPLICATION# <br /> 1 m <br /> 'To {c <br /> OWNER NAME C PHONE [ 5'Q N <br /> OWNER ADDRESS n( 5509 CITY/STATE/ZIP <br /> HOD <br /> CONTRACTOR (r1^^Iwiv,��{{''� r ,�_IAILnlY�1L/\ PHONE /1/� �/c <br /> CONTRACTOR ADDRESS CaL;1_0 W l l.U �Q,� CITY/STATE/ZIP UI L(X �L.T J goo `y <br /> SUBCONTRACTOR/CONSULTANT A& PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESSITY/STAATT��t!E//ZIIPP <br /> LICENSE }LSC-57 El C-61 ❑ D-09 11 Other NUMBER 4R,81 EXPIRATION DATE <br /> BILLING PARTY_ ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) 1 Dibromochloropropane(4392)❑ Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well 0 Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings 0 Geotechnical #of borings <br /> ❑ Out-Of-Service Well 0 Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump KPump Replacement ❑ Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary ❑ Air Rotary 0 Auger 0 Cable Tool 0 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 0 Steel ElPlastic ❑ Stainless Steel 0 Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> 0 Bentonite(20%solids) ❑ Other <br /> Grout Placement Method 0 Pumped 0 Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP Submersible❑ Turbine ❑ 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 /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORK S OMPENSATION LAWS. <br /> MM AD E NOTICE REQUIRED FO INSP ONS -PLEASE CALL (209) 76 <br /> SIGNED TITLE DATE ( V <br /> E14T <br /> D <br /> 020 <br /> CIA Q NOUNT`( <br /> VI O NTAL <br /> E <br /> TMENT <br /> QE,S;�'ARTMENT USEKrON Y <br /> Application Accepted By Date -/ ?_v Z v Area // I Employee lD# lz4r( a� <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By a;�L% `u Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount at Permit/ Invoice# Well ID# <br /> Codes Info C sh Remitted -4&1 1/ Service Request# <br /> I w Poo 41105 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />