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Domestic/Private 0 Irrigation/Agricultural C Industrial C Water Quality Monitoring <br />ublic Water System <br />If different from Owner: Water System Name <br />EI Soil Sampling/Characterization <br />Contact Name or Phone Number <br />INTENDED USE <br />WELL/PUMP PERMIT <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS CVa0 <br />1868 EAST HAZELTON AVENUE - STOCKTON CA 95205-6232 (209) 468-3420 <br />WWW.Sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />CITY/ZIP LOdit qsavo <br />Cu- <br />PARCEL SIZE/ 0 LAND USE APPLICATION # <br /> 1 ,,PHONE 16 -cisq -aocto <br />watciTy,sTATE,z,p ,.4 q5Y-40 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />NON-REFUNDABLE PERMIT <br />SUBCONTRACTOR/CONSULTANT PHONC/14.. <br />CITY/STATE/ZIP <br />EXPIRATION DATE 3/ DJ NUMBER <br />SUBCONTRACT R/CONSULTANT ADDRESS ic x <br />LICENSE -57 E 0-61 E D-09 C Other <br />BILLING PA‘TY: OWNER SUBCONTRACTOR/CONSULTANT CONTRACTOR <br />DOMESTIC WELL SAMPLING: I General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />TYPE OF WORK New Well 0 Replacement Well C Well Alteration/Modification LI Other <br /> <br />Monitoring Well(s) <br />Ei Out-Of-Service Well <br />New Pump <br /># of wells C Soil Boring(s) # of borings <br />Out-Of-Service Well Renewal <br />Pump Repair <br />Geotechnical <br /> # of borings <br />Pump Replacement <br />Cross-Connection Repair <br />Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Ei Mud Rotary 111 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth ft Excavation in diameter E Open Bottom C Gravel Pack/Gravel Size in diameter <br />El Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel C Plastic E Stainless Steel C Other <br />Grout Seal Depth <br /> <br />ft 0 Neat Cement (94 lb bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) 0 Other <br />Grout Placement Method E Pumped C Free Fall C Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By El Driller 0 Pump Contractor 0 Other <br />Concrete Pedestal :Dimensions: Width ft Length ft Thick in E Christy Box C Stove Pipe <br />PUMP Oubmersible 0 Turbine E Other HP Pump Set ft Standing Water Level <br /> <br />ft <br /> <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 />WORK S\COMPENSATION LAWS. <br />TNC411 TI E REQUIRED FO <br />TITLE <br /> I SECT ONS - PLEASE CALL (209 <br />DATE :SSBHOCIV 311E fr <br />weoL, <br />11(.2Z-1-1 <br />D. P USE ONLY <br />PAYmENT <br />REce ivED <br />SAN JoAQuiA, <br />ENV/RoivUEVL N ry <br />11E-AL.Th D <br />ENT <br />1m" <br />SEP 2019 <br />SIGNED <br />Date <br />Date <br />Date <br />Date <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />cJ 1— \loA191\ fre,siN U12IQ <br />Area Area Employee ID# <br />PECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC <br />Info <br /> Received < Chec Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# x13 c.ash <br />4,g( (0 ti. Jtv 15615- I q 7 7 61111(13 boo jo itayis <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT