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WELUPUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT vvvvvv.sjgcrv.cfrgiehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Gt 21 CITYILP ` m <br /> CROSS STREETAPN� o J PARCEL SIZE 1 LAND USE AAPPPLICA(TIIOON,(r#'j raA <br /> OWNER NAME 1 '� PHONE aa) <br /> 7 <br /> OWNER ADDRESS e �-p t� `.1' �'D (' 'CITYISTAT'EEMP <br /> CONTRACTOR L1 t D,,J-M 12 t/J if-ril 1C�'C O 1 icy � �M'Ct��jP1OWNEE '�7 <br /> CONTRACTOR ADDRESS 11,✓� U I I` 1] �C 3 Vy CITY/STATE/ZIP "'-X%rl-A J L <br /> SUBCONTRACTOR/CONSULTANT 6, PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATEIZIP <br /> LICENSE )XL:-57 11 C-61 i I D-09 f i Other NUMBER 0 EXPIRATION DATE S7 3 I a <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDE12 USE ��Domestic/Private Irrigation/Agricultural 1 I Industrial I i Water Quality Monitoring Ll Soil SamplinglCharacterization <br /> 1 Public Water System <br /> If digerela from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK n New Well n Replacement Well n Well Afterstion/Modification n Other <br /> ii Monitoring Well(s) #of wells U Soil BDring(s) r of boring' L,Geotechnical t'of borings <br /> U Out-Of-Service Well ❑Out-Of-Service Well Renewal U Cross-Connection Repair <br /> ew PUME LJ Pump Replacement U Pump Repair O Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method l MukCasi <br /> o Aug I I Cable Tool i I Push Point I Other <br /> Proposed Well Depth Excavation in d' ter IJ an Bottom a Gravel Pack/Grav Size in diameter <br /> L1 Conin diameter / for Casing DepthWell Casing Diamekness/Gauge/ASTM d u Steel astic a Stainless Steel I erGrout Seal Depth U Neal Cement Ib bag/5- gal water) U a ement ck mix17 gal water <br /> u Ben ) Il Other <br /> Grout Placement Method u Pumped U Free Fall U Other U Retardant/Accelerator(name) <br /> PEDESTAL In talled By L Driller Pump Contractor 0 Other <br /> Concrete Pedestal ODimensions:Width_It Length ft Thick in Il ChristyBox ❑Stovs Pips <br /> PUMP Submersiblel I Turbine 1 Other HP Pump Set ft Standing Water Level ft <br /> 1 WILL HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK LL 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 COMPENSA710WS. <br /> AlNliqgM 48 URA OTICE REQUIRED FOR INSPECTIONS--PLEASE CALL(209))95 -7f697 <br /> SIGNED TITLE -�� "' `� T DATE ` l <br /> cyMFNT <br /> ? 2020 <br /> Ully <br /> pgRT�UNTY <br /> MENTI <br /> DEPARTMENT U E NLY <br /> Application Accepted By f�=« Date / c�JAS 0 Area �� Employee IN <br /> Grout Inspection By C11111 — <br /> - Date SPECIAL Well Permit <br /> Pump inspection By L-r.C.%I;L V1111 — `L Date �I�3Irj69,�C WAIVER Received <br /> Soil Boring IpApection By Date Constructed Well Depth It <br /> COMMENTS P14r ill'! �Tf li? I Ve' 140F <br /> R/ <br /> PE SC Received Check#/ Amount Date PermlV Invoice# Well IN <br /> Codes Info B Cash Remitted Service Requestill <br /> ti '� Jsl -IS <br /> ENO a31M 6/11/(019 <br /> WELL/PUMP PERMIT <br />