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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,P MIT ww.s ov.or lehd ---/���, fEXPIRES 1 Y rR�FROM <br /> {q DATE ISSUED W <br /> ( CITY/ IP 4 ti� ��'� ° 6 m <br /> JOB ADDRESS ` r Y p E ar D <br /> ( r, ( ,� 7 <br /> �UY ApN �U 1��� PARCEL SIZE LAND USE APPLICATION# A <br /> CROSS STREET m <br /> t) � ejcAC r Y, y <br /> ONE <br /> OWNER NAME dmf !p {j/ /6�j -?'7 -7 <br /> CITY/STATE/ZIP l V a <br /> OWNER ADDRESS I //�'�• �/ �/ t y� i y/�y <br /> 2 1/ ( I) PHONE <br /> CONTRACTOR \! <br /> L •+�,, J CITYISTATEI�P � <br /> CONTRACTOR ADDRESS PHONE <br /> ) <br /> 4rY <br /> SUSUBCONTRACTOR/CONSULTANT �( <br /> ! CITY/STATE/ZIP r / <br /> SUBCONTRACTOR/CONSULTANT ADDRESS <br /> 12-7 <br /> LICENSE _ C 57 a C-61 _ D-09 a Other <br /> �j NUMBER EXPIRATION DATE <br /> BILLING PARTY: OWNER ri CONTRACTOR 7 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: n Genera! Mineral/Coliform Bacteria(4391) = Dibromochloropropane(4392)❑Arsenic(4393) <br /> ng _ Soil Sampling/Characterization <br /> INTENDED USE Domestic/Private u Irrigation/Agricultural _ Industrial _ Water Quality Monitori <br /> Public Water System Contact Name or Phone Number <br /> If different from owner: Water System Name <br /> TYC5 RIF WORK _ New Well a Replacement Well u Well Alteration/Modification J Other #of borings <br /> Monitoring Wells) #of wells ❑ Soil Boring(S) <br /> #of borings - Geotechnical <br /> \ _ out-Of-Service Well . u Out-Of-Service Well Renewal uCross-Connection Repair � <br /> -_ New Pum [i pump Re lacem nt 7� Pum��7 Repaiir C Raise Well Casing <br /> rEOINSTRUCTION U P f kr <br /> Method _ Mud Rotary u Air Rotary u Auger _ Cable Tool L_ Push Point Othed Well Depth ft Excavation in diameter u Open Bottom L Gravel PacklGravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> r) Steel a Plastic _ Stainless Steel ❑ Other <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched <br /> Grout Seal Depth <br /> ft � Neat Cement(94 Ib bag/5-10 gal water) n Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) I Other n Retardant/Accelerator(name) U <br /> Grout Placement Method - Pumped n Free Fall n Other <br /> PEDESTAL Installed By - Driller ❑ Pump Contractor C Other <br /> _ C�Submersible <br /> te Pedestal uDimensions:Width ft Length ft Thick in _ Christy Box u Stove Pipe <br /> PUMP - Turbine n Other <br /> Hp L 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 CAOUNTY ND C ORDIWITH THESCAL FORNIA CONTRACTORSLAWS, AND RULES NSTATEU LICENSE BOARD AND RTHAT I AM NTIFY THAT YCOMPLIANDCE REQUIREIW LCENTH <br /> CURRENTALL <br /> WORKERS COMP S ON LAWS. <br /> MINIMU HOUR AQ�ANCE NOTICE REQUIRED FO INSPECF�TS -y/PLEA SE CALL(209)�5 �6�7 -- <br /> TITLE � C1' )C1 J DATE �7 1 <br /> SIGNED <br /> 7� <br /> i <br /> S N O UN O N <br /> H LTH DE7,A77MIENT <br /> l DEPARTMENT USE ONLY <br /> Application Accepted By ---�L Date p/ZZ)1'20'1P Area $ �! _ Employee ID#ER <br /> Grout Inspection Bynn Date ❑ SPECIAL Well Permit <br /> Pump Inspection By 1SC �nG.� • 4ti -Ls�— Date ����i`-p�h� 11 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date permit/ <br /> Codes Info B Cash Remitted Service Request# Invoice# Well ID# <br /> y3sa oso 3D(6 f-77 I I I ID Ix WYO <br /> EHD 43-06 6/11/21)19 <br /> WELL/PUMP PERMIT <br />