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e_ <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 /> JOB ADDRESS �IIornt-r �� �-GUJ�S��i,r�rnz �pF� i w' Z\v, Cm21P m <br /> CROSS STREET V�Gt APNI/JU5� PARCELSIZE7,G( OLD <br /> LAND USE APPLICATION# v <br /> m <br /> OWNER NAME C"C /1 Yl PHONE 4y <br /> OWNER ADDRESS D`� S 1 n F IQ I p(_ -(�- CrrY/STATE/ZIP o n k l u-t i ?l�/t_� �I S Cl <br /> 17 <br /> CONTRACTOR I P/'�f�CO(� ltll �n�S f P`1 O 'ISV(� PHONES <br /> CONTRACTOR ADDRESS �f�,� SSG`t,�'�r` q\ W'y CITY/STATE/ZIP <br /> i� <br /> SUBCONTRACTOR)CONSULTANT L 1 PHON �} <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CrTY/STATE/ZIP <br /> LICENSE )(C-57 C-61 D-09 ❑ Other NUMBER490 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 X Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 1) New Well A Replacement Well i Well Alteration/Modification Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Borings) a of bonngs �.Geotechnical _ or borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump i Pump Replacement rl Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary I- Air Rotary X Auger Cable Tool Push Point C' Other <br /> Proposed Well Depth_6_1� ft Excavation 401 � in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel ❑ Pla6fic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack rl gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP ❑ 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 WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 1lJINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209)953-71697 <br /> SIGNED /(^^E. TITLE IF±�1 Cjc'CIO`j(Sfi DATE <br /> Q in <br /> v <br /> sA <br /> n <br /> F <br /> DEPARTMENT USE O LY <br /> Application Accepted By �� _ Date 11 'D� Area b Lq G e IDEmployee I .- <br /> Grout Inspection By �� K, Date I j, L D SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS 1{ 1n({r IS F1,76c,) -e f".41O)P 16 4;ie )ezy <br /> PE SC Received Chtac Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Re uest# <br /> EHD43-06 6/11/2019 <br /> WELL/PUMP PERMIT <br />