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W'F"LAILIFOUNIP PERMIT <br /> -SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE,STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABL .PERMIT _— vW�!?ltN.s P�`::=orglehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> _r 7-Co17 ccj ToAw <br /> T( � CITYi?IP m <br /> JOB ADDRESS <br /> y�� Q� ���,, <br /> �• ��// " API+! y"! —( PARCEL SIZ LAND USE�4PPLICAT!O/N#J <br /> 'GROSS STREET1410 <br /> �"- � -'------ SuA! (]J�/,�I ✓ `I o <br /> i r`L(1�1A1///l (� V V_J P ONE <br /> 01NNEF NfarYtE MV� ���C -- J 6 c(G <br /> OWNER,$DDRESS -- _ r lTl'1S iF- J <br /> �/ Cr4 I! �-- �' C-- PHONE C�q Qj" <br /> CONTFACTOR � ��� `� _- I� ,/_ <br /> C ! V6 { 6 CITY/STA7e , _� , <br /> CONTRACTOR ADDRESS_ "/_ — w <br /> itA <br /> SUBCONTI7ZACTOPJCONSULTANT wl J _ rHCNE� -- <br /> -- A I I off. <br /> _ <br /> 1A - <br /> SUF3C7fdTF:ACTOP./CONSULTANTADDRESS <br /> %!TY/STATE2iP__ <br /> ^ � " '" DATE—_� <br /> ��_�I__ NUMBER � EXP!RAT10N 3 wa <br /> ,LICENSE _ G57 XC-o1 _ D-09 _ Otha:r_� -------� � r1 <br /> BIL:JNC:PARTY OWNER >(CoNrki CTOR _ SUBCONTRACTORICONSULTANT ---_-� <br /> _General iVlinarailCcli`orr Bacteria(4391) := Dibromochloropropane(4392)-Arsenic(4393) <br /> ;..r•..mu_o,iGSivr_'LL k�r1FLIPiv: _ — -'-1 ' <br /> IATEhiDED 1JSf Domestic/Private - Initgaticr;/,• ij1CWturai _ Industrial Water Quality Monitoring _ Soil Sampling/Characterization i <br /> I - Public Water System--_,___� -- Contact Name or Phone Number f <br /> If differ*int from Owner. — l°Dater System Name <br /> TYPE OF:WORK - New Well Replaces hent Well Well Alteration/Modification _ Other R of bunnns <br /> -- Monitoring Wells)—_— #of vveiis - Soil Boring(s) <br /> #of borings - Geotechnical <br /> —^ _ Out-Of-Service -211 _- Out-Of-Service Well Renewal _ Cross-Connection Repair <br /> Raise Well Casing <br /> = New Pump <br /> Pur Replacsmerit Pump Repair --; <br /> !`,(DEL L.CONSTRUCTION'-- I I n <br /> l I:)rilling Mlethod - Mud Rotary - ;"sir rRotarv, _ Auger -_ Cable Tool Push Point _ Other_ <br /> ?-oposed Well Depth____ —ft Excavation in diameter _ Open Bottom _ Gravel Pack/Gravel Size in aiamete <br /> - Conductor Casingin dinmete: i Conductor Casing Depth — ft <br /> _.—.—_ rpt <br /> Well C.esing Dj?nneter_—• in Thi:knc It ougei,�,S iM Sched _: Steel Plastic _ Stainless Steel ;: Other_,_„•—._.....___ <br /> Grout Seal Depth_ ¢: <br /> Neat Ce m<;ni(V4 tb!rag/5 1 J oa!water] Sand Cement sack mix(7 gal water <br /> Bentonite(20%scalds) Cither___�-,_ <br /> Grout Placement Method - Pumped -._Free Fall -: Other _ Retardant/Accelerator(name)_ <br /> '3?GDES7AL Installed By Driller Pump Contraaor = Other - - - <br /> Concrete Peaestal'_Li:mensions:Width Y _Length ft Thick— in _ Christy Box _Stove Pipe - i <br /> r`- -- —�—-1.., ' —^ IIP Pump Set ft Standing Water Lavel <br /> ft j <br /> Pr-^R�r. Submer>rb _Turbine <br /> Other r - - ___ <br /> I HERESY CERTIFY 'THAT i HAVE PRiwr-'.f,F:EU THIS APPLICATION ANIS THAT THE WORK WILL BE DONE IN ACCORDANCE `dJiTH SiA,N <br /> JOAQUIN COtlNTY ORDINANCES, STATE i.A?4S. AND RULES, AND REGULATIONS, I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND A( ii WITH THE CALIFORNIA CONTRrC7ORS STATE LICENSE BOA-RD AND THAT I AM. IN COMPLIANCE adail:i AL.' <br /> vi:trkM:E'?S cOM€y- irj1N LAWS. <br /> ✓ wr�� Nem_ CALL ;:;�'7?f <br /> MrN,AV0 A.1VIi9� L - UrC , <br /> SIGNED--- —_ ------- -- — <br /> TITLE_ 5" ir ► U M CA V ) DATE <br /> -� <br /> -I i- , - I 1 <br /> 7-1 1 T i i- <br /> -4— <br /> DEPARTMENT USE ONLY MFNT <br /> Application Accepted By - � Date 13 l Did Area Employee ID# Fie <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By V nA'5 LZ ( :c �b Date V �`l/U-b 7 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS - <br /> PE SC Received he Amount Permit/ <br /> Date Invoice# Well ID# <br /> Codes I Info B Cas Remitted Service Re uest# <br /> WELL/PUMP PERMIT <br /> EHD 43-06 6/11/2019 <br />