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1092 <br /> 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 /> JOB ADDRESS 3425 Section Ave. CITY/ZIP Stockton 95205 m <br /> D <br /> CROSS STREET Golden Gate APN 1 73-09-016p <br /> PARCEL S IZE ()b10 LAND USE APPLICATION# p <br /> M <br /> OWNER NomF Jose Rodriguez PHONE 209-898-6686 rv' <br /> OWNER ADDRESS SAME CITYISTATEIZIP <br /> CONTRACTOR De 1 f z�l PHONE <br /> CONTRACTOR ADDRESS 13!L ''' V' <br /> ('- C.YV�� WIt CITY/STATEIZIP i-la-A <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATEIZIP <br /> LICENSE C-57 X C-61 D-09 Other NUMBER 10554)4 EXPIRATION DATE 7?31;2021 <br /> BILLING PARTY: ,OWNER -CONTRACTOR I SU13CONTRACTOPJCCNSULTANT <br /> DomESTIC WELL SAMPLING:I General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE X Domestic"Private Irrigation;Agricuttural -- Industrial Water Quality Monitoring L Soil Sam pli nglCha racterization <br /> I Public Water System <br /> `drf event from CX-rer Water System IJeroe Con-act Name or ntcne'4umber <br /> TYPE OF WORK I Nevi Well I Replacement Well I Well Alteration/Modification Other <br /> Monitoring Well(s) #of yells I Soil Boring(s) 'I r"'' ''' Geotechnical nii J <br /> Out-Of-Service Well I Out-Of-Service Well Renewal Cross-Connection Repair <br /> Nevi Pump X Pump Replacement L Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method I Mud Rotary - Au Rotary Auger I Cable Tool Push Point F Other <br /> Proposed Well Depth It Excavation in diameter -1 Open Bottom Gravel Pack.Gravel Size in diameter <br /> Conductor Casing in diameter Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness,GaugerASTM Sched J Steel _ Plastic _ Stainless Steel ! Other <br /> Grout Seal Depth It I Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mtx.7 gal water <br /> _ Bentonite(201%solids) L Other <br /> Grout Placement Method Pumped I Free Fall I Other I Retardant r Accelerator(name) <br /> f PEDESTAL Installed By -1 Driller r Pump Contractor -1 Other <br /> ! Concrete Pedestal _.Dimensions:Width ft Length It Thick in __ Christy Box ! Stove Pipe <br /> PUMP x Submersible I Turbine i Other HP 1 Pump Set 700 ft Standing Water Level 40 ft <br /> 1 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 /> IR A-VANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE -:ALL(209)9F7-769: <br /> SIGNED_ _ L TITLE CEO DATE 10127x2020 <br /> r <br /> . � Ems,; <br /> DEPARTMENT USE ONLY <br /> Application Accepted By �� Date I( dodo Area Employee ID# FF <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By �6,,,116rCC1,,"4i kt,�Z-- Date 5'1141 WAIVER Received <br /> Soil Boring Inspection By _ Date _ Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well IDN <br /> Codes InfoB Cash Remitted Service Request# <br /> l LA <br /> 1-1043-06, C 1CIC19 'AF I +1`I11;IPaFRN'IT <br />