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WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTIvIEN7 i aG8 EAST-HAZEL!ON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT wwjq <br /> w.s <br /> qy.orc,,.[!ehd I EXPIRES 1 YEAR FROMJDATE ISSUED <br /> jJ06ADDR=S3 —TW Pet -vo 0 4 <br /> 11Q"th <br /> i jor,ADDRESS -I,TylzlF- <br /> Vl <br /> M <br /> > <br /> a <br /> ,CROSS S-rRFFT AP N go —PARCEL SIZE LA USE APPLICATION <br /> M <br /> OWNER NAME J_Q tyLR S r) o� ;fhI'3rHD D <br /> -Nfk - <br /> (o <br /> O%AnqrrADDRESS "ITYISTf — Cf <br /> :1 ' <br /> CONTRACTOR PHCNF9 a ao <br /> ADD CITYISTATEAFOOU <br /> i,CONTRACTOR RESS CO q5?'gb <br /> 'SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOWCONSULTANIT ADD ESS CITY!STA7EF&1P <br /> L.ICEISISr C-57 /\-(C-61 D-09Othe EXPIRATION <br /> '-TOP <br /> BI;-LING P A RTY: X C014TRACTOR SURCONTR.— <br /> DOMEST:C WELL SAMPLING: 7 General Mineral/Coliform Bacteria(4391) = Dibrornochloropropane(4392)---Arsenic(4393) <br /> INTENDED USE Domestic/Private 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 Other <br /> "of <br /> - Monitoring Well(s)— #of wells - Soil Boring(s) borings Geotechnical 'I 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 <br /> Urilling Method - MLIb Rotary - Air Rotary - Auger - Cable Too] Push Point Other <br /> i Proposed Well -Depth_ -;t Excavation in diameter Open Bottom I- Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing s Steel - Plastic _ Stainless Steel �j Other <br /> Diameter in Thickness/Gauge/ASTM Gauge/ASTM Sched <br /> Grout Seal Depth_ ft Neat Cement(94 lb bFg15-10 gal water) 7 Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) = Other <br /> Placement Method - Pumped 7 Free Fall Other Retardant/Accelerator(name) _J <br /> I PEVESTAL Installed By _- Driller 7 Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width <br /> ft Length ft Thick in Christy Box Stove Pipe <br /> :- <br /> r <br /> PUFJIP XsUbmersible- Turbine ' Other HP Pump SetLJ.QL_ft Standing Water Level I t, - ft <br /> 1 HEREBY CERTIFY THAT 1, 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 /> ViORKERS COMPENSA:rIONI LAWS. <br /> M 48 HID A VA, C E ME REQUIRED FOF�,NSPECTIONS - PASSEE <br /> LECALL (209) 95;-7697 <br /> SIGNED 4;12" TLE_ rvIUMayl DATE t 13jZb <br /> 14 <br /> T� <br /> Fai <br /> J_ <br /> ANP <br /> i JUIN <br /> 4; sm <br /> IMUN4111nm <br /> `7 hFAI�TH I)ErA�T�E�T <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date 121_oqldo;�v Area 3A_c4 I Employee ID# FR' <br /> Grout Inspection By Date 0 SPECIAL Well Permit <br /> Pump Inspection By Date aps-L t❑I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS W;+�t)M 1j1rvtIJ3r rinCl 4J GlIS�r <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted vi re Request# <br /> 9391 050 3 y 477 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />