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S1 <br /> 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 WWW.S Ov.Qr /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITVRIP <br /> CROSS STREET H l;SS J APN PARCEL SIZE IV LAND USE APPLICCA,ION# <br /> OWNER NAMEIVt �Cit /I1/► G'L�T' PHONE v v <br /> OWNER ADDRESS .� ��Y Y'� ' CITY/STATE/ZIP \ G C)� Oct <br /> CONTRACTOR C I 1 PHON'E'I'V ( / ( <br /> CONTRACTOR ADDRESS \ ///// � CITYISTATE/ZIP Qt 1 LIrl <br /> SUBCONTRACTOR/CONSULTANT G,) PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS Cr YISTATEILP <br /> LICENSE $? C61 .D-09 .Other NUMBER <br /> xPIRATION DATE Cq <br /> BILLING PAf _.OWNER CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:j(General Mineral/Coliform Bacteria(4391),1 Dibromochloropropane(4392)_:Arsenic(4393) <br /> INTENDED USE ADomestic/Private Imgation/Agricultural _Industrial :Water Quality Monitoring :Soil SamplinglCharactenzation <br /> Public Water System <br /> If different from OvmerWater System Name Contact Name or Phone Number <br /> TYPE OF WORK L ew Well Replacement Well Well Alteration/Modification 7,Other <br /> Monitoring Well(s) #of wells ❑Soil Boring(s) #of WrI gs ❑Geotechnical #of b.'ngs <br /> C Out-0f-Service Well C Out-0f-Service Well Renewal L Cross-Connection Repair <br /> 7 New Pum Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling M.I—h 5TMud R tarry�� Air Rotary C Auger Cable Tool :-,Push Point Other <br /> Proposed Well Depth_9 \i ft Excavation k,)—, in diameter 7 Open Bottom -J.,ravel Pack/Gravel Size in diameter <br /> Conduc r Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 7 In Thickness/Gauge/ASTM Sched�I��1 Steel'X,7lastic i:;Stainless Steel C Other <br /> Grout Seal�th h ft Neat Cement(94 lb bag/S10 gal water) n Sand Cement sack mixl7 gal water <br /> antonite(20%solids) Other <br /> Grout Placeme t Method -,114nioed L.Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By n Driller Pump Contractor - Other <br /> 7.Concrete Pedestal Li Di a sions:Width it Length ft Thick in Christy Box :i Stove Pipe <br /> PUMP Submersible­Turbine -Other HP Pump Set ft Standing Water Level h <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 ACTTVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI UR/Jr��[��NCE NOTICE REQUIRED FOR I SPrLECT 1R\NQS-JP1EASE CALL(20 )9 -17697 <br /> SIGNED �/ TITLE �t� ` `-l/a DATE <br /> I <br /> RE YMFN <br /> N ,o 112 /IV <br /> N 2s 2020 <br /> AC HDFPgRTMFNTY <br /> / DEPARTMENT <br /> USE NLY �j <br /> Application Accepted By ` Date Fi JA 5 J l� Area /G/r Employee ID# <br /> Grout Inspection By �- _ Data 2ci 11 SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth _r ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Pe�U Invoice# Well ID# <br /> Codes Into Cas Remitted Service R uest# <br /> ��y5 <br /> ` s'r," S 7 J (✓ ��j L� 1 I r <br /> EHD43-06 8/118019 WELL/PUMP PERMIT <br /> �. &; -�/1a/,F63F/ <br />