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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.01 /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS S /v,�n! CITYILP m;> <br /> D <br /> CROSS STREET ^��f/,� C� JJ�/f� APjN/y�9 3 �I J✓� yPAARCCEEL SIZE J•)` LANG USE APPLIICATIONN�# A <br /> OWNER NAME l /"^0S /f/�L/L�//� //y/\�I // �/\.�C� — PHONE `/ /y-ny5 j 7 w <br /> OWNER ADDRESS �`l 6. = � �/�'/r-cTY/STATEIZIP <br /> CONTRACTOR L �L- PHOYNEj�� /,�fn ��3� <br /> CONTRACTOR ADDRESS CITY/STATE/LP <^'�/✓ Gi'i / .�C <br /> SUBCONTRACTORICONSULTANT �< L/ �L�7 PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STA <br /> �TE/ZIP �7 <br /> LICENSE N-57 -61 D-09 Other NUMBER �V'J/ ? EXPIRATION DATE <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DoMEsnc WELL SAMPLING:General Mineral/Coliform Bacteria(4391)Dibromochloropropane(4392)_.Arsenic(4393) <br /> INTENDED USE Domestic/Private -I Irrigation/Agricultural - Industrial .Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contac)Name or Phone Number <br /> TYPE OF WORK New Well eplacement Well Well Alteration/Modification -Other <br /> Monitoring Well(s) #of wells Soil Boring(s) a of bonne, Geotechnical a or borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> ew Pum _Pum Replacement '_Pum Repair .Raise Well Casing <br /> WELL CONSTR nON <br /> Drilling Method>0tMud Rotary iJ Air Rotary Auger , able Tool Push Point Other <br /> Proposed WeIK Depth�R Excavation�! in diameter Open Bottom YeiGravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameter in Thickness/Gauge/ASTM SchedvL SleelfPlaslic Stainless Steel Other <br /> Grout Seal Depth If Neat Cement(94 lb bagl5-10 gal water) Sand Cement sack mixr7 gal water <br /> 1Aemonite(20%solids) ❑Other <br /> Grout Placement Method -Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By _Driller kfPump Contractor Other <br /> Concrete Pedestal Imensions:Width R Length R Thick in Christy Box .. Stove Pipe <br /> PUMP ubmersible,,- Turbine Other HP L Pump Set L R Standing Water Level 1 R <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 AWS. ff1c/�I SO/vL ��'� � �L► <br /> iv• ( VANC NOT?Cc'REQU FOR(I{/N^SP CTIUt\I5 PLEASE CALL(209)95,W69 <br /> SIGNED y TITLE ✓ DATE77- <br /> N <br /> NY41, <br /> le���VE'D <br /> 0r <br /> ,DDEPARTMENT U E ,10 82020 <br /> Application Accepted By y C'/� Dale J Z�0 0 Area Employee ID#�R co <br /> Grout Inspection By ** -- L- Date '(i'�r�Z�L� SPECIAL Well Permit �zpO , i4 <br /> Pump Inspection By�(Joit S I_:+ �°�^�'— Date qL'."4 WAIVER Received TMEHT <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received NChecjIAV Amount Date Permitl Invoice# Well ID# <br /> Codes Info By Cash Remitted Sprvice Re uest# <br /> N K D: /S ci <br /> �l 6F iBo b - zU' n <br /> /za370 111 <br /> EHD 43-06 6/112019 WELL/PUMP PERMIT <br />