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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.sjgov.org/ehd EXPIRES 1YEAR FROMDATE ISSUED <br /> so <br /> JOB ADDRESS l.�d SGLJ Hou-/ CITY/ZIP 1�/d CO`// . cf'5 2-37 m <br /> D <br /> CROSS STREET 1 J LS C� APN ��I'-I V D- )- PARCEL SIZE LAND USE APPLICATION# <br /> �7nC z <br /> �1�GLVC� j>o n n I ��r ,f GtX'm�Yc f�NYI� PHONE <br /> OWNER NAME _ I n <br /> OWNER ADDRESS I qG 5 D D 166h R uLA CITY/STATE/ZIP --Of 2 CCl• _I � � <br /> r <br /> CONTRACTOR J 4 / PHONE <br /> CONTRACTOR ADDRESS 6ClL CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS �J�I 1 f CITY/STATE/ZIP <br /> LICENSE J C-57 I_ C-61 C D-09 )(Other 9L°I NUMBER EXPIRATION DATE <br /> BILLING PARTY: AOWNER L CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)C Dibromochloropropane(4392)[-1 Arsenic(4393) <br /> INTENDED USE (g Domestic/Private U Irrigation/Agricultural U Industrial C Water Quality Monitoring U Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK C New Well i Replacement Well !- Well Alteration/Modification C Other <br /> Ll Monitoring Well(s) #of wells " Soil Boring(s) <br /> #of borings Geotechnical #of borings <br /> Out-Of-Service Well I I Out-Of-Service Well Renewal i_l Cross-Connection Repair <br /> I-1 New Pump F1 Pump Replacement 1 1 Pump Repair Raise Well Casin <br /> rWELLNSTRUCTIONMethod C Mud Rotary C Air Rotary J Auger Cable Tool ❑ Push Point 7 Other <br /> d Well Depth ft Excavation in diameter - Open Bottom U Gravel Pack/Gravel Size in diameter <br /> Ci Conductor Casing in diameter / Conductor Casing Depth ft <br /> asing Diameter_ in Thickness/Gauge/ASTM Sched Steel I Plastic Stainless Steel D Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) i-i Other <br /> Grout Placement Method CI Pumped I-1 Free Fall 0 Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By L Driller ❑ Pump Contractor I Other <br /> C Concrete Pedestal LJDimensions:Width ft Length ft Thick in C Christy Box C Stove Pipe <br /> PUMP U Submersible Turbine 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 WIT THE CALIFO NIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION S. <br /> UM ADV NOTICE REQUIRED FOR <br /> INSPECTIONS -PLEASE CALL (209) 995j3-7697 �/� <br /> SIGNED TITLE V�I KJY _ DATE L/ �''�v <br /> .l q <br /> AL T N O <br /> R <br /> ———— —— T——T————————— ——— <br /> f DEPARTMENT USE ONLY <br /> Application Accepted By �' �/� Date * ld do"�o Area Employee ID# IFS <br /> goat Inspection B' l7 Date G 7f /I 5 POK) - SPECIAL Well Permit <br /> r <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS Well ,rlhs� n ! <br /> be CunDR':� w/h�tee u✓�+I'e��ic � St'c",�orloYPrQttPr rPm<ilhlhG a� a� PrY!"CP TJr �,Ve �/PurS <br /> the Dyret•ror y"cAy cc 11 ia�r Elle 1� b� I 6cndo»e ww- .ter– - <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Request# <br /> 43G`1 )7s <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />