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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />qI D(1-10 r-vorf(Ap <br />www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />GICo rtilue <br />OWNER ADDRESS Kuumry D>0 cawsTATEizipp <br />CONTRACTOR ki-ft kbwvio uuttAits TIAA PHONE:2061 <br />CONTRACTOR ADDRESS g5a-- . 1 1 4--t— DX) ...S1) CITY/STATE/Zilla(il• 6/n7(a <br />SUBCONTRACTOR/CONSULTANT <br /> <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CITY/STATE/ZIP <br />BILLING P <br />A LICENSE1( C-57 C-61 D-09 Other NUMBER IVA/9)0 EXPIRATION DATE 6— I ) (981 <br />TY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPUNG: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE l omestic/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 />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 Cross-Connection Repair <br />WELL CONSTRU2ISS <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool <br />Proposed Well De ft Excava 'on in diamete Op Bottom Gra <br />Conu o Casing in dia / Conductor Casin ft <br />Well Casing Diame r in Thickness/Gauge TM Soiled Steel Plastic Stain <br />Grout Seal Dep ft Neat 94 lb bacg/5-10 gal w Sand Cement <br />entonite (20% solids) <br />Grout Placement ethod Pumped Free Fall Other Retarda t / Accelera (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width Length hick In Christy Box Stove Pipe <br />PUMP i(Submersible Turbine Other HP Pump Set jtal ft Standing Water Level ft et <br />I HEREBY CE TIFY 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 />DVANCE NOTICE REQUIRED FOR INSP CrioN - PLEASE CALL (209) 953/697 <br /> DA AT af <br />(3 (AN, <br />\nr ) <br />DEPARTMENT USE N L Y <br />Application Accepted By Date D Area Sig 4, Employee ID# 701,1,_ 2 1 F It <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By -rlrnnt45 [ 0 laorim:.._ OJAI. 1 Date ev;iterLI WAIVER Received J <br />ft Soil Boring Inspection By Date Constructed Well Depth <br />COMMENTS /4e vt/ eik 1 I vi POO Lio‘dg <br />PE <br />Codes <br />SC <br />Info <br />Received Check#/ <br />h <br />Amount <br />Remitted Date i Permit/ <br />Service Reques # Invoice # Well ID# <br />93go osi (A_ _igeaitCapiy- *Is-07 *At/Ileum- <br />.. <br />EHD 43-06 6/11/2019 /2.0Z,5--q72 WELL /PUMP PERMIT <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />APN <br />arazip <br />• <br />PARCEL SIZE C? 7 LAND USE APPLICATION # <br />PHONOSA 1/ 2) --VI a() <br />TYPE OF WORK <br />Push Point Other <br />in diameter <br />UM 4 <br />SIGNE TITLE