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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.s Ov.Of /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 630 E . Cle-ve .5+ CITYIZIP fo.c 1$37(0 LA <br /> L�I1 <br /> CROSS STREET N. /M a GAr1I,,l tier APN 2150-as-o�yn <br /> PARCEL SIZE LAND USE APPLICATION# A <br /> In <br /> OWNER NAME PHONE ryn <br /> OWNER ADDRESS CITYISTATEZP d <br /> CONTRACTOR -Tr-C rO�Gd/% PHONE �O�l- 3167 3 701 <br /> CONTRACTOR ADDRESS W- nr�u3�-r�A I Wo-`/ CITY/STATE/ZIP �' lJ <br /> OI/ a <br /> CA l y,^*Io <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACT/OR/CONSULTANT ADDRESS C, j <br /> ITTY/STATE/7jP <br /> LICENSE /I C-57 - C-61 LI D-09 n Other NUMBER"'6 q60 1 EXPIRATION DATE.5/31/;-/ <br /> BILLING PARTY: _OWNER Ll CONTRACTOR L' SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:n General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private n Irrigation/Agricultural []Industrial D 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 n New Well n Replacement Well F Well Alteration/Modification ❑Other <br /> I Monitoring Well(s) #of wells I,Soil Boring(s) #of borings /Geotechnical a a of borings <br /> I Out-Of-Service Well A Out-Of-Service Well Renewal ❑Crass-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTIO <br /> Drilling Method Mud Rotary [I Air Rotary Auger n Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth 151 540 ft Excavation Q/' 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 Schad ❑Steel -1 Plastic Stainless Steel :-]Other <br /> Grout Seal Depth 15 SO ft Neat Cement(94 lb bag/5-10 gal water) F.1 Sand Cement sackmix/7 gal water <br /> a Bentonite(20%solids) Other <br /> Grout Placement Method _Pumped L]Free Fall ❑Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By []Driller ❑Pump Contractor ❑ Other <br /> o Concrete Pedestal DDimensions:Width ft Length ft Thick in L Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible[]Turbine ❑Other HP Pump Set ft Standing Water Level It <br /> 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 /> NIMUI 488 HOURADVANCENOTICE REQUIRED FOR INSPECTIONS-'^PLEASE CALL(209)1953-7697 <br /> SIGNED t/ TITLE F Y lrinr,..`��An f V 1UNa.4r r DATE <br /> I <br /> N <br /> I FENT <br /> 52020 <br /> J <br /> IOUAL <br /> DEPA- TMENT US r�O LY <br /> Application Accepted By Date N Area _ Employee ID# <br /> Grout Inspection By . Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring In action By Date Constructed Well Dep(h ft ` <br /> CO DENTS L ( <br /> • TK <br /> PE SC Received Check#I Amount Permit/ <br /> odes Info B Cash Remitted Date Service Re nest# Invoice# Well ID# <br /> EHD 43-ee 8/112018 /t A. WELL/PUMP PERMIT <br />