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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.org1ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS oMll v'QLn <br /> _ Q, CITYIZIP Ciel ( �y/ —L D mI <br /> CROSS STREET ✓ Jf kiu FP APN,)_ qA0 v 1 / PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME 6-0 V)v-+f ^a I'l lJ�/ I PHONE �u2q ( ��2 M <br /> OWNER ADDRESS 7l/_V V \'(/ J�/�/,� CITY/STATE/ZIP rl/ <br /> CONTRACTOR 0%4-te w d DrI1 1 111 Y 'vL PHONE 01/%(�[ (4f <br /> CONTRACTOR ADDRESS P0 �UXo I qL CITY/STATE/ZIP�.I Vw"Y IJ✓� `4,S s <br /> SUBCONTRACTOR/CONSULTANT ��/ PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/Z <br /> IP <br /> LICENSE X C-57 i_j C-61 D-09 '7 Other NUMBER �lK EXPIRATION DATE <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)ADibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural 7 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 I7 Well Alteration/Modification Other <br /> I Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well , Out-Of-Service Well Renewal - Cross-Connection Repair <br /> New Pump D Pump Replacement Pump Repair -: Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method'C Mud Rotary 11Air Rotary ❑ Auger Cable Tool ❑ Push Point L! Other <br /> Proposed Well Depth - ft Excavation ' in diameter I_i Open Bottom ,(Gravel Pack/Gravel Size in diameter <br /> Conduc r Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sche6y� a1 ❑ Steel lastic L1 Stainless Steel 1-1 Other <br /> Grout Seal Depth ` ft 1 Neat Cement(94 Ib bag/5-10 gal water) _ Sand Cement sack mix/7 gal water <br /> 1x5entonite(20%solids) I Other <br /> Grout Placement Method -Pumped _i Free Fall ❑ Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Pump Contractor -: Other <br /> Concrete Pedestal ❑Di ensions:Width ft Length ft Thick in Christy Box Cl 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 /> WORKERS COMPENSATION LAWS. <br /> MINIMUM(iArtA NC OTICE REQUIRED FO INSP CITIIO,NSS-PLEASE CALL(209) 953- 697 <br /> SIGNED TITLE Y L/� DATE �7, <br /> F /N <br /> Ly <br /> DEPARTMENT USE ONLY FN7' <br /> Application Accepted By �`� r Date 10/0 L0 Area � �C7 Employee ID# DA <br /> Grout Inspection ByDate�� I H i-Z C ZA SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By �/ Date Constructed Well Depth ft <br /> COMMENTS r;XIS�1)qG, vie ll �12 berls R� If i7~ no /017G6f �nLlibnS �nS Jrl� irul/ C�cici7�,J% /f Ci;rnO <br /> C ro �'�;t ,nc frc 1 �� o✓ i h 11 , ' �FufF ylsu 'e theft ;P lyfoy beooir� <br /> K Jc <br /> 'pr= Sc Received Check# Amount Date PermiU Invoice# Well ID# <br /> Codes Info B s Remitted Service Re uest# <br /> llanl td we 0041500 <br /> 3(i 1 I s"o 0 2 0e ooqt2) 0 <br /> 43eU 170 10110 I I D <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />