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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 YEA�RyFFRROM DATE ISSUED <br /> JOB ADDRESS �✓ CITY/ZIPIle <br /> m <br /> 1 11 D <br /> CROSS STRE APN / v� PARCEL SIZE 1 LAND USE APPLICATION# o <br /> OWNER NAME ,{ ��? ` PHONE 7 r cChi� <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR � /�- � l� C� PH,Oe�NYE� <br /> CONTRACTOR ADDRESS 7 CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANTC� p_osx PHONE 32 s l <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE -%&-57 ❑ C-61 ❑ D-09 ❑ Other NUMBE �r <br /> RI-2�� O EXPIRATION DATE <br /> BILLING PARTY: 1 :OWNER i CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:X General Mineral/Coliform Bacteria (4391)Dibromochloropropane(4392) i7 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 /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal El Cross-Connection Repair <br /> `4ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 4<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 /> ❑ Conducto Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ''Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depthft ❑ Neat Cement(94 Ib bag/5-10 gal water) >16 and Cementsack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method RfPumped ❑ 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 .*I�Submersible❑ Turbine ❑ Other HPA= <br /> 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 /> MINIM 48}HCOV AD/AAINCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209)953-7-697 <br /> SIGNEDcy^C�C/`l�. w///!�"� TITLE DATE <br /> DEPARTMENT USE ONLY 1 {� <br /> Application Accepted By ' Date ws,L v?O�t7 Area / rC Employee ID# D� <br /> \ VL- \A ���9u 0 SPECIAL Well <br /> Grout Inspection By '(rty�5\� r �.. Date <br /> Pump Inspection By Date a WAIVER Rec 4A 1ov <br /> Soil Boring Inspection By Date Constructed Well Depth, ft <br /> COMMENTS �Pwclil I <br /> SAA, "UZU <br /> IA, <br /> PE Sc Received heck# Amount Date Permit/ Inv# O ME/yT I�I D# <br /> Codes Info B ash Remitted Service Request# H D ^^r�- <br /> �I3?,D L) 00 \\y� Nr <br /> Llgc, $v <br /> N301 � I sc7 <br /> 4— <br /> 3<<a o <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />