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LyPUMr PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)4683420 <br /> NON-REFUNDABLE PERMIT c VVWW.S OY.o ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> F�ADDRE S r 7 ��r11O.n� CITY21P / / r�G- T <br /> ce <br /> B© �'wy APN� 3�vlt/���D P.S. a <br /> LAND USE APPLICATION a p <br /> jkn IQ orze PHONE} PO I ' ! <br /> CITY/STATEEZP �/ <br /> ;:EPCDNTRAGTDR f_ 9 6 ONf ly�y�c 7 <br /> CONTRACTOR ADDRESS �02 CfY/STAT21P /t <br /> SUBCONTRACTOR/CONSULTANT <br /> S <br /> ISE <br /> SUBGONTRACTOR/CONSULTANT ADDRESS CRYISTTATEIZIP V A <br /> LICENSE )L�-57 I C-61 C D-09 C Other NUMBER_l 60&.AC ? ExPiRATION DATE /0 <br /> BILLING PARTY: D OWNER ONTRACTOR D SUBCONTRACTORICONSULTANT �_�,I�►� <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)U Dibromochloropropane(4392)G Arsenic(4393) <br /> INTENDED USE 7 DomestictPrivate .Inigation/Agricutturel C Industrial D Water Quality Monitoring C Sold sampling/Characterization �`✓f <br /> Public Water System /1 <br /> it dlRerarlt from Owner: Walar System Name CaRaCt Wme Or Phar Number <br /> TYPE OF WORK /Newwell D Replacement Well C Well Alteration/Modification D Other i <br /> C Monitoring Well(s) #of wells O Soil Borfng(s) 9 of bwr'91 ❑Geotechnical 7t of borings <br /> Out-0f-Service Well Out-OfService Well Renewal i i Cross-Connection Repair <br /> i New Pump2 Replacement..L Pump Repair Raise Well Cali <br /> WELL CONSTRUCTION <br /> Drilling Method,4Mud Rotary D Air Rotary n Auger "Cable Tool C Push Point C Other <br /> Proposed Well Depth�ft Excavation_ 1&j in diameter C Open Bottom (Gravel Pack/Gravel Size <br /> IF <br /> in diameter <br /> 7 Conductor Casing in diameter ! Conductor Casing Depth ft <br /> Well Casing Diameter I/ Thickness/Gauge/ASTM Sched S r 2 7 Steel plastic C Stainless Steel 0 Other <br /> Grout Seal Depth ft Neat Cement(941b bag/5-10 gal wafe <br /> r) <br /> Ssack-.7 gal Water <br /> Cement <br /> Bentonite(20%solids) 'I Other <br /> Grout Placement Method ❑Pumped C.Free Fall ❑Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By -1 Driller f Pump Contractor n Other <br /> 0 Concrete Pedestal]Dimensions:Width_It Length ft Thick in D Christy Box C Stove Pipe <br /> PUMP -_Submersible❑Turbine D Other HP Pump Set It 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 /> MINIM 48 HOUR ADV¢NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED <br /> TITLE Gf '12-'`�-7 <br /> O <br /> PACE V <br /> RE <br /> NIA`( 13 11 <br /> SAN JOAQUIN <br /> HeNTH pEPA <br /> A�- 7yJ DEPARTMENT USE ONLY tfl <br /> Application Accepted By G,�Z-� Date s /,2 .2020 Area => ��C Employee ID# S k <br /> Grout Inspection By ate . C SPECIAL Well Permit <br /> Pump Inspection By , Date G WAIVER Received <br /> Soil Boring Inspection By Dale Cony�ru�ted Well Depth fl <br /> COMMENTS L - C�:..:C 1�C.y,l,'( S _ /), <br /> �L <br /> Vi C <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info Cash Remitted Date Ce R ue t# Invoice# Well ID# <br /> EHD 43-O6 61112019 <br /> WELL/PUMP PEF7A1(r <br />