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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 EXPIRES 1 YEAR FROM DATE ISSUED <br /> u � <br /> JOB ADDRESS 425 CITY/ZIP Z m <br /> 9 ry7 D <br /> CROSS STREET APN O 0 PARCEL SIZE 1 r V LAND USB APPLICATION# o <br /> X <br /> cn <br /> OWNER NAME V, PHONE <br /> OWNER ADDRESS �f 258 N 14 ulne_ Ed CITY/STATE/ZIPj(J(,�C4 /✓f��7 J� <br /> CONTRACTOR �-�ObY YY1CtX1 5 We-teir vYAMS 1 n c � 1• PHONE 1 31 <br /> ?� W` <br /> CONTRACTOR ADDRESS 2-� I (DX 1���• CITY/STATE/ZIP �C in, C / SZks- <br /> SUBCONTRACTOR/CONSULTANT 4 PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br /> BILLING PARTY: ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane(4392) ❑ Arsenic(4393) <br /> INTENDED USE 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 0 Other <br /> 0 Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump Pump Replacement ❑ Pump Repair ❑ 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 0 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 0 Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped 0 Free Fall 0 Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor 0 Other <br /> ❑ Concrete Pedestal ODimensions:Width ft Length ft Thick in ❑ 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 I AM IN COMPLIANCE WITH ALL <br /> WORK S OMPENSATION LAWS. <br /> MI U CE NOTICE REQUIRED F IN IONS -PLEASE CALL (209) -76 <br /> SIGNED EAR ) TITLE DATE <br /> N <br /> AAA <br /> At <br /> U CoLNTI <br /> IRON <br /> HEAL <br /> Lo <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date �/ [ "� Area 1 Employee ID# <br /> Grout Inspection By Date q ❑ SPECIAL Well Permit <br /> Pump Inspection By �t w.I .�f� p¢�(i�h Date 101�1ij,0 ❑ 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 A 9YA Cash R mitted Service Request# <br /> L PO 4l <br /> EHD 43-06 6/11/2019 <br /> WELL/PUMP PERMIT <br />