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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 c EXPIRES 1 YEAR/F\ROM DATE ISSUED <br /> JOB ADDRESS r>�y� SCtt�h 6\igo'r �: ( CrTY/ZIP Stc(�"t o 1 `��J 206 m <br /> D <br /> CROSS STREET v `I-- )�� JT�'�� APN)JJ�-7 O 3 LI PARCEL SIZE 1`3�',3 LAND USE APPLICATION# S <br /> rn <br /> OWNER NAME �-(D'1 (1�i i./ Y l./J f y PHONE y <br /> OWNER ADDRESS ' I, CI Y/STATE21P <br /> CONTRACTOR I�Vr�,c,;y,� L�•tJn17CtnkS ,Lr//�l. ,I`Vet 1 l 0 ♦�1'Y�lS�h ' 'PJIHONE(/ <br /> �Vl <br /> W <br /> CONTRACTOR ADDRESS � �I} �i'�, cCm/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT N f PHONE` I �� I <br /> SUBCONTRACTOR/CONSULTANT ADDRESS i V f CITY/STATEIZIP I V <br /> [I / <br /> LICENSE �C-57 ❑ C-61 m D-09 Other NUMBER VbCla)y EXPIRATION DATE�- QJ"�' <br /> BILLING PARTY: ❑OWNER n CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)_1 Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring X 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 Other <br /> Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings )(Geotechnical I C #of borings <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump i I Pump Replacement i Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary C Air Rotary X Auger ''Cable Tool Push Point D Other <br /> Proposed Well Depth �V ft Excavation Of G 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 ISteel Plastic Stainless Steel Other <br /> Grout Seal Depth it Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped X Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ❑ Pump Contractor Other <br /> Concrete Pedestal nDimenslons:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible " Turbine I 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 /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR <br /> ADVANCE NOTICE REQUIRED FOR INSPECTIONS -1PLEASE CALL (209)953-7697 <br /> J <br /> SIGNED f`�!'V TITLE J, (J�J�G�)1S1 DATE 7020 <br /> AL I <br /> L. <br /> r = <br /> S. <br /> h <br /> DEPARTMENT USE ONLY <br /> Application Accepted By L fr� Date 11;LdOdU Area / P Em to <br /> Grout Inspection By Date ElSPECIAL Well Pef?nPRI, <br /> Pump Inspection By Date WAIVER Recelve*) U �© <br /> Soil Boring Inspection By w �5 c: �. L Date ll i 1:j, Constructed Well Depttb ` ft <br /> COMMENTS q <br /> Eq/ ON OU <br /> PE SC Received (Check#!' Amount Permit/ <br /> Codes Info B -ICash Remitted Date Service Request# Invoice# Vve1i <br /> i s APX­ 114 <br /> EHD 43-06 6/11/2019 WELL!PUMP PERMIT <br />