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Cock Sbr�r� <br /> 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 EXPIRES 1 YEAR FROM DATE ISSUED <br /> Q <br /> rn <br /> I <br /> JOB ADDRESS Cj;L(1 • ff1pt�lt. `� CITY/ZIP Lo \y ����I O m <br /> CROSS STREET tr�thV Y �++V I.i APN OLI� PARCEL SIZE I� ( D <br /> LAND USE APPLICATION# X <br /> OWNER NAME �'S.l_(sfpL'i I C P-51 C KZ�S �l`f f- PHONE y <br /> OWNER ADDRESS �. l�UJl S S / (� J CITY/STATE/ZIP L 0 d) -� <br /> CONTRACTOR _Te"C\G0n �il�^SH)'`t /1J�1c�` Vr nV�5D ,,PHONE <br /> Iw % 3 1 3-101 <br /> CONTRACTOR ADDRESS 1v � N�'TV`�\ t""•"7' CITY/STATE/ZIP Z'\ ; 0� <br /> SUBCONTRACTOR/CONSULTANT /`�'� PHON/IE <br /> / <br /> SUBCONTRACTOR/CONSULTANT ADDRESS �`Ih CITY/STATE/ZIP N/ I� <br /> LICENSE )iC-57C-61 D-09 ❑ Other NUMBER 4 O b H EXPIRATION DATE <br /> BILLING PARTY: OWNER ❑CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:_ General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring /11(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 i Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #°f b0ff"gs Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump J Pump Replacement 'I Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary C Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth J� ft Excavation 0 in diameter Open Bottom Gravel Pack/Gravel Sizej�ldj deter D <br /> Conductor Casing in diameter / Conductor Casing Depth ft 9 <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other SAN <br /> Grout Seal Depth >; ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement s Ib/ <br /> Bentonite(20%solids) Other �T/y MF �NTy <br /> Grout Placement Method Pumped X Free Fall Other Retardant/Accelerator(name) ENT <br /> PEDESTAL Installed By u Driller ❑ Pump Contractor Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP n Submersible F! Turbine rl 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 /> M IMU/'jM/y 8 HOUR DVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 953-7697 <br /> SIGNED !'. TRLE s�i��T Gcc�y)"S' DATE ID/600)0 <br /> N <br /> DEPARTMENT USE <br /> /do <br /> ONLY <br /> Application Accepted By f _ Date o)v <br /> (J b Area �/ Employee ID# <br /> Grout Inspection By _ Dale SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection B Date Constructed Well Depth ft <br /> COMMENTS C, �� / tin/t- <br /> Cklik 4- _�.' r &ucIn 1 �• ;nc . ctC� v' " <br /> PE SC ReceivedCheck#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info ash Remitted Service Request# <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />