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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 1 YEAR FROM DATE ISSUED <br /> V <br /> JOB ADDRESS 1 Oak 'K-51-31") <br /> CROSS STREET APN yr�D <br /> P RCEL SIZE I O LAND USE APf�PLICAT�IO.Nr#'j/� ./ A <br /> OWNER NAME /\�1 �CA o 1`1�/`�����/11�� I IS n PHONE�yC4 (ell V�-7k-cl <br /> OWNER ADDRESS S 1 ( t-61'1./ OCA ll.. 1—f k ^,CITYISTATE/ZIP Lc,t <br /> CONTRACTOR OJ '}\tel I t�\�y ''�,Jr . EQ it (1.1-i (/� PHONEJ <br /> CONTRACTOR ADDRESS 1 6 1✓ V J� Ll c4u CIITYISTATE(ZIP <br /> SUB CONTRACTORICONSULTANT PHONE <br /> 5UBCONTRACTORICONSULTANT ADDRESS CITYISTATEIZIP <br /> LICENSE K C-57 U C-61 0 D-09 -Other NUMBER � EXPIRATION DATE V <br /> BILLING PARTY: 'J OWNER L CONTRACTOR L; SUBCONTRACTORICONSULTANT <br /> DomesTe WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE Domestic/PrNate - irrigation/Agricultural -1 Industrial -Water Quality Monitoring D Soil Sampling/Characterization <br /> 7 Public Water System <br /> If different tom CMmer: Water5ystem Name Conrad Name or Phone Number <br /> TYPE OF WORK )(New Well 'Replacement Well L Well Alteration/Moddication LI Other <br /> 0 Monitoring Well(s) #of wells 0 Soil Boring(s) eofbormp It Geotechnical •ofborings <br /> 0 Out-Or-Service Well ❑Out-Of-Service Well Renewal [I Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement n Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method'XMud Rotary D Alr Rotary 0 Auger. -�JCable Tool 0 Push Point U Omer <br /> Propo5eo Well Depth�Q 'tF- <br /> R Excavation�In diameter 0 Open Bottom /{Gravel PacklGravel Size in diameter <br /> duc <br /> Conin diameter / Conductor Casing Depth n <br /> Well Casing D;ameter Thickness/Gauge/ASTM Schetl,,�Dd,21 11 Steel X Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth t ft 0 Neat Cement(94 to bag/5-10 gel water) CI Sand Cement sack mixf7 gal water <br /> ABentonite(20%solids) ❑Other <br /> Grout Placement Method Pumped 0 Free Fall 0 Other Ll Retardant/Accelerator(name) <br /> PEDESTAL Installed By -lDriller Pump contractor II Other <br /> J Concrete PedestaI'Dimensions.Width It Length It Thick in C Christy Box ❑Stove Pipe <br /> ❑Submersible-Turbine -Other HP Pump Set ft Standing Water Lovoi 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 /> MINIMU A/,rt\SVA.. JOTICE REQUIRED FOR I PE'TC I NS,•/PLEASE CALL(209 963-7697 <br /> SIGNED ����,k�1✓ V TITLE M 1 ��'Y DATE N <br /> � cF��ED <br /> - CT <br /> San,J 30 2420 <br /> IV <br /> 71 <br /> a R rMFNr <br /> i <br /> DEPARTMENT USE ONLY <br /> Application Accepted By .er%��� Date 11""71 vl,/�`1 Area ~� / r' Employee ID# <br /> Grout Inspection By A Date I Z ❑ SPECIAL Well Perrnit <br /> Pump Inspection By Data ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth h <br /> COMMENTS <br /> PE Sc Received Check#/ Amount ate Permit/ Invoice{ Weil DOCodes Info B n Cas Remitted erviceRe uestiC <br /> -r I. <br /> EHD 4106 6/118019 WELL NUIVP PERMIT <br />