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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.Sgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Law Y) Rc�JOB ADDRESS s , CITY/ZIP �► (/lvv}� m <br /> D <br /> CROSS STREET A�P�NII19 <br /> �/ PARCEL SIZE �� LAND USE APPLICATION# A <br /> OWNER NAME (/(v✓ A PHONE 20q, "`Q �3O N <br /> OWNER ADDRESS iivl vv'V 111V CITY/STATE/ZIP ` `�' /" ` J <br /> CONTRACTOR t/1 (D 1 vvV`(��rI I�(1� i ` P1HpO'N��IJ'I/-`,�I'/jz' <br /> CONTRACTOR ADDRESS 1 0 �o) 1 �` CITY/STATE/ZIP R_( V�� �v w 1 r <br /> SUBCONTRACTOR/CONSULTANT ► \1 /v PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> C—fq ) <br /> BILLING <br /> LICENSE C-57 P. C-61 ❑ D-09 11 Other NUMBER { EXPIRATION DATE C CJ <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 ❑ 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 WORKNew Well ElReplacement Well ❑ Well Alteration/Modification 11Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ElGeotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pum ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method/ Mud Rotary ❑ Air Rotary ❑ Auger -Ll Cable Tool iiPush Point 11Other <br /> Proposed Well Depth Q d ft Excavation )iin diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conducor Casing in diameter / CongLucttor Casing 111111g Depth ft <br /> Well Casing Diameter1�in Thickness/Gauge/ASTM Sched5 Steel Plastic Stainless Steel Other <br /> Grout Seal Depth V ft ❑ Neat Cement(94 Ib bag/5 10 gal water) G Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ DrillerPump Contractor ❑ Other <br /> 11 Concrete Pedestal ❑Di ensions:Width ft Length ft Thick in C Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ 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 COM ATION LAWS. <br /> MINI UM UR CE NOTICE REQUIRED FORS EPTIONS-PLEASE CALL ((209) i-76 7a <br /> SIGNED TITLE <br /> E <br /> J ' 11 DEPARTMENT USE ONLY T <br /> application Accepted By v li Date 3 �3 Zv1� Area 5 Employee ID# DGr <br /> Grout Inspection By Date 17/1oy� ❑ SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received _ <br /> Soil Boring Insp ction�y Date Constructed Well Depth ft <br /> COMMENTS — P -11 tJ <br /> PE SC Received hec Amount Permit/ <br /> ('odes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> Lax; 180 ya a <br /> �13�i I I y 5-- " <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />