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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 96205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT .S OV.Of /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> JOB ADDRESS CITYIZIP m <br /> �+ D <br /> CROSS STREETfAQV APN J 3107' PARCEL SIZE _qCLLAND USE APPLICATION# n <br /> OWNER NAME /PHHONJ lal?3-2D a9 <br /> OWNER ADDRESS CITYISTATE/Z1P I.V(,{/l� ( " qS fL� <br /> CONTRACTOR PHONE ZQ?-�/��l <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP-6ni2 m M9�ats <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS ITY/STATE2IP <br /> LICENSE ]C-57 D C-61 0 D-09 0 Other NUMBE EXPIRATION DATE T ( —� <br /> BILLING PARTY: ❑OWNER ❑CONTRACTOR G SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELLS X <br /> PLING:C General Mineral/Coliform Bacteria(4391)G Dibromochloropropane(4392)C Arsenic(4393) <br /> INTENDED USE X <br /> DomesticlPrivate 0 Irrigation/Agricultural D Industrial D Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Omer. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK D New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> C Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings 0 Geotechnical #or borings <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump ?(Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point C Other <br /> Proposed Well Depth It Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched 0 Steel C Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth ft 0 Neat Cement(94 Ib bagl5-10 gal water) 0 Sand Cement sack mix/7 gal water <br /> 0 Bentonite(20%solids) 0 Other P <br /> Grout Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant/Accelerator(name) �� <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal[]Dimensions:Width ft Length ft Thick in C Christy Box 0 Stove Pipe <br /> PUMP Submersible 0 Turbine 0 Other HP Pump Set ft Standing Water Level ft ®� <br /> I HEREBY CE TI THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH IV O ?©20 <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE I� AQu <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH V1'10 N L'O(� <br /> WORKERS ICOMPENSATION HZO�WS NCE NOTICE REQUIRED FOR INSPCTIONS-PLEASE CALL(209)953 97 �C H O�P'9R MFN� <br /> SIGNED�l �' TITLEi//v/�"� DATE �z <br /> RA I <br /> 44 2 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By "` Gf� Date Area Employee ID# <br /> Grout Inspection By �q^^ r- Date ❑ SPECIAL Well Permit <br /> Pump Inspection By i't&A r ;1 t u st��a�r Datelaal� ❑ WAIVER Received <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 Remitted Service t# <br /> 3Y OS O f;77 <br /> END 4306 6/11/2019 WELL/PUMP PERMIT <br />