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WELL/PUMP PERMIT <br /> SAN JCAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> (VON-REFUNDABLE PERMIT WWW_.SjgOV.orq/ehd E) PIRES 1 YEAR FROM DATE ISSUED <br /> L , 1C a � 5Z � O m <br /> JOB ADDRESS ' ry q CITY/ZIP D <br /> �1 CO I(�n APN <br /> CROSS STREET PARCEL SIZE LAND USE APPLICATION# p <br /> rJ m <br /> RHf�ol <br /> r en U � ;PHO( "N U� '��� � y <br /> OWNER NAMEADDRESS `� v CITY/STATE"` �I v " <br /> (OWNER <br /> (CONTRACTOR " /J() �' / —T r6 !,/�P� CHO—N�Ey� <br /> 7 V I d Co C;CITY/STATE IPV J 1 V J / Q <br /> (CONTRACTOR ADDRESS ll r <br /> SUBCONTRACTOR/CONSULTANT Ir� PHONE �l <br /> IV <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 1y / CITYISnTATEIZIP X <br /> LICENSE _ C-57 X, C-61 _ D-09 _ Other //J1 Z_j NUMBER A W (A+' 0 EXPIRATION DATE <br /> BILLING PARTY: OWNER CONTRACTOR 7 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: _-General Mineral/Coliform Bacteria(4391)_ Dibromochloropropane (4392) D Arsenic(4393) <br /> 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 L; Replacement Well a Well Alteration/Modification Other <br /> - Monitoring Well(s) #of wells 7 Soil Boring(s) #of borings - Geotechnical #of bor ngs <br /> _ Out-Of-Service Well L; Out-Of-Service Well Renewal � Cross-Connection Repair <br /> _ = New Pump Pump Replacement D Pump Repair = Raise Well Casing �- <br /> WELL CONSTRUCTION <br /> (Drilling Method _ Mud Rotary Air Rotary u Auger _ Cable Tool L 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 N <br /> Well Casing Diameter_ in ThicknesslGauge/ASTM Sched Steel L� Plastic _ Stainless Steel u Other S <br /> Grout Seal Depth ft n Neat Cement(94 lb bag/5-10 ga!water) Sand Cement sack mix/7 gal water p <br /> t - <br /> = Bentonite(20%solids) Other <br /> Grout Placement Method _. Pumped -I Free Fall n Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By -_ Driller ❑ Pump Contractor Other <br /> Concrete Pedestal UDimensions:Width ft Length ft Thick in _ Christy Box a Stove Pipe <br /> PUMP )Submersible- Turbine n 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 ACTT E WITH THE CALIFORNIA C(.)N T RA TORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP ATION LAWS. <br /> (MINIM 48 HOUR ADVANCE NOTICE REQUIRED FO�,ANSP^ECTI,( LAO��NS - PLEASE CALL (209) 3- 97 <br /> SIGNED U <br /> TITLE t )?yA'I'U1l Y I y/1 DATE <br /> - <br /> I � <br /> i <br /> I <br /> i <br /> t 1 <br /> Q IN rc <br /> - ( I <br /> 9r,1 <br /> H E 14 <br /> E <br /> 4RTN� <br /> DEPARTMENT USE ONLY <br /> Application Accepted By 1—� Date /6 dii'0 Area_q Employee ID# FR. <br /> Grout Inspection By Date C SPECIAL Well Permit <br /> Pump Inspection By i` 5�0 06[lt A'� �� Date �Ik J tll-0 til) I,' WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received heck# Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Remitted Service Request# <br /> 47 • 2- <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />