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Ad1wn <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� w4W.�5.gov.org/ehd / `� EXP ES YEAR FROM DATE ISSUED <br /> JOB ADDRESS '" 1 / r La <br /> CITY/ZIP �U m <br /> D <br /> CROSS STREET V r ./�� APN_as 9oa o I s PARCEL SIZE ��v� LAN USE APPLICATION# / 0- <br /> OWNERNAME `� +-� -• vPH1 1 /� +'z / L/ �yi+ <br /> OWNER ADDRESSTATE( 1gn . . cl[ 1,5 ,O _ <br /> CONTRACTOR Vu WV lin ,n,/J L C <br /> " PHONE <br /> 7 t c 1lSic Gt S v <br /> CONTRACTOR ADDRESS n CITY/STATE <br /> SUBCONTRACTOR/CONSULTANT fV PHONE �/ C <br /> SUBCONTRACTOR/CONSUV LTAANT ADDRESS , th 7,] CITY/STATE/ZIP W/ <br /> fF <br /> LICENSE _ G57 \ C-61 _ D-09 _ Other f/! NUM W s+� O EXPIRATION DATE <br /> (BILLING PARTY: OWNER 7 CONTRACTOR 1 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: D G% Ifeneral Mineral/Coliform Bacteria (4391) = Dibromochloropropane (4392 u 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 U Replacement Well J Well Alteration/Modification Other <br /> Monitoring Wells) #of WellsF1Soil Boring(s) #of borings - Geotechnical of borings <br /> Out-Of-Service Well ut-Of-Service Well Renewal Cross-Connection Repair <br /> - New Pump ❑ Pump Replacement - Pum Repair _ Raise Well Casingn <br /> WELL CONSTRUCTION <br /> Drilling Method _ Mud Rotary U Air Rotary Auger _ Cable Tool L Push Point _ Other <br /> Proposed Well Depth ft Excavation in diameter. _j 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 Sched _j Steel J Plastic _ Stainless Steel U Other <br /> Grout Seal Depth ft n Neat Cement-(94/b bag/5-10 gal water) �1 Sand Cement sack mix/7 gal water <br /> = Bentonite(20%solids) ❑ Other R <br /> Grout Placement Method - Pumped n Free Fall n Other n Retardant/Accelerator(name) Uj <br /> PEDESTAL Installed By = Driller D Pump Contractor C Other <br /> _ Concrete Pedestal L;Dimensions:Width ft Length ft Thick in _ Christy Box U Stove Pipe <br /> PUMP Submersible- Turbine f HP Pump Set ft Standing Water Level V tOft <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 l AM IN COMPLIANCE WITH ALL <br /> WORKERS COMFE SATION LAWS. <br /> N1iNIrM) r 48 HOUR ADVANCE NOVICE REQUIRED FOR iNSPECTIONS - PLEASE CALL (209) 95 .-76;97;. <br /> SIGNED �� TITLE `' � DHV <br /> Q E� R `i <br /> v \i <br /> \C^o M\ <br /> I <br /> N r Vo Q I <br /> NT <br /> / DEPARTMENT USE ONLY �I <br /> Application Accepted By Z'L— Date /v O� �O.?� Area 1 Employee ID# F9 <br /> Grout Inspection By Date L SPECIAL Well Permit <br /> Pump Inspection By (P4,4ei5[,C lYG7:p F w',j, Date 4Y LJ 1-1 WAIVER Received <br /> r <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted S rvice Request <br /> y3$a Oso 77 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />