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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 /> N <br /> JOB ADDRESS J� /J�� � /1/ CITY/ZIP j/J / 5,7: <br /> CROSS STREE�i� /�/� APN S7 S Od vl PARCEL SIZE L D 4E APPLICATION# o <br /> OWNER NAME /� � .//! /'- / ��11�1/7 l7lrpL16 PHONY 3/ 3-5Zav N <br /> OWNER ADDRESS -'CS ��`� CITY/STATE/ZIP --------- <br /> CONTRACTOR // �� r � PHONE <br /> ry �3l�r�/� <br /> CONTRACTOR ADDRESS ! /��D� CITY/STATE/ZIP �5fA;/ <br /> SUBCONTRACTOR/CONSULTANT �— PHONE r� <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE )/ -57 C-61 D-09 _ Other NUMBER 7� G� EXPIRATION DATE <br /> BILLING PARTY: OWNER _ CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private L Irrigation/Agricultural - industrial _ Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well _ Replacement Well Well Alteration/Modification i Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump ump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION 111 <br /> Drilling Method _ Mud Rotary _ Air Rotary Auger _ Cable Tool _ Push Point Other <br /> Proposed Well Depth ft Excavation in diameter _ Open Bottom _ Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft _ Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method _ Pumped _ Free Fall _ Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal _Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP ubmerslbie_ Turbine _ Other HP Pump Set ft 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 /> MI8 O AN/�CCE/NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209)/95?-76 <br /> SIGNED /J`'� any%� �� TITLE�� �%�/(�c� DATE f 7 <br /> JAC 1A <br /> 1 O <br /> OP M <br /> T E <br /> DEPARTMENT USE ONLY <br /> Application Accepted Date Ia op Area "1 Employee ID# <br /> Grout Inspection y Date IC SPECIAL Well Permit <br /> Pump Inspection By 1rc n(�S �� �Q�„�_ ti ;V Date I It h42 1-t I WAIVER Received <br /> Soil Bor'ng Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC ReceivedChe Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Re uest# <br /> 3� Oso I( D`42 47 <br /> EHD 43-06 6/'1/2019 WELL/PUMP PERMIT <br />