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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZEL TON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT wyvw.sjgov.org/ehd XPIRES YEAR oM DATE ISSUED <br /> .toe ADDRESS an' CITY/ZIP G � `^ 1 m <br /> 1 i yA rr�-��"� D <br /> CROSS STREET c iTY 9c p ArP�rNy/ 30d� PARCEL SIZE I OCII.IND USE APPLICATION a®n <br /> OWNER NAME + s !G 1 S 6 Ve! l_A _ _ PHONE_� m <br /> M <br /> a� y� ,/� <br /> OWNER ADDRESS �/V 1 Y I 1 - CITYISTATEIZIP <br /> CONTRACTOR �ZT PHONE <br /> C <br /> CONTRACTOR ADDRESS `f�' �/ �✓l Y CITY/STATE/ZIP � �� JQ <br /> SUBCONTRACTOR/CONSULTANar"�/ P ONE <br /> SUBCONTRACTOR/CONSULTANTADDRESS �1 CITY/STATE/Z1P l `;\ <br /> LICENSE _ C-57 3C-61 _ D-09 Other _ NUMBERD-1 WaI60 EXPIRATION DATE- 3 jzd <br /> BILLING PARTY: - OWNER X CONTRACTOR 1 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria(4391) = Dibromochloropropane(4392)❑Arsenic(4393) <br /> I INTENDED USE Domestic/Private - Irrigation/Agricultural _ 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 Well Alteration/Modification Other <br /> - Monitoring Well(s) #of wells 7. Soil Boring(s) #of borings - Geotechnical #of borings <br /> _ Out-Of-Servic ell Out-Of-Service Well Renewal Cross-Connection Repair <br /> = New Purip Pump Replacement E Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method .- Mud Rotary U Air Rotary Auger _ Cable Tool I_ Push Point _ Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom L Gravel Pack/Gravel Size in diameter <br /> _ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched -j Steel a Plastic _ Stainless Steel U Other <br /> Grout Seal Depth ft F1 Neat Cement(94 lb bag/5-10 gal water) �I Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) -7 Other <br /> I Grout Placement Method - Pumped n Free Fall n Other i� Retardant/Accelerator(name) <br /> PEDESTAL Installed By -- Driller D Pump Contractor C Other \ <br /> _ Concrete Pedestal U!Dimensions:Width. ft Le th ft Thick in _ Christy Box U Stove Pip <br /> PUMP ubmersible- Turbine n Other ht� PUMPS dft Standing Water Level___ —ft <br /> -WAT' .PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> .ANCES, STATE LAW"Zi, iaNU IWLES'AND REGULATIONS. i :ALSO CERTIFY THAT MY RL-QUIRED LICENSE IS <br /> -L;(jRiGrvt APId A E WITH THE CALIFORNIA GONTRAGTOPS STATE LICENSE RCARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP A ON LAWS. <br /> MINI a ADVANCE NOVICE REQUIRED c0 iiNSPE,C'TIONS -PLEASE CALL (209) 51-7697 <br /> SIGNED _ TITLE <�- , V[1J� � DATE <br /> I I <br /> I <br /> I _ <br /> f � <br /> C <br /> tK ii I N q (0) C U <br /> -f <br /> PA TM N <br /> I I I I I I I I I I I I I I I I I I I I I <br /> DEPARTMENT USE ONLY <br /> Application Accepted By 2-��f Date 10 d Area I q Employee ID# �V <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By ; nAL I �Co j n 1n rLL,L au,L Date 10 1 1.1-0-D ❑ 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 B Remitted Service Re uest# <br /> ►-138 aS,o 7 <br /> EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />