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jr 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 ww)N.sjgov.ctrg1ehd EXPIRES'I YEAR FROM DATE ISSUED <br /> y� 53O'� <br /> JoBADDREss 3�0 5 . CITYIZIP J rQ C� m <br /> � arc /�'^ ryDD <br /> CROSS STREET s APN 255 (JLo-OS PARCEL SIZE _LAND USE APPLICATION <br /> en L..an G PHONE <br /> OWNER NAME T m <br /> OWNER ADDRESS • CRY/STATE21P 1 �� <br /> CONTRACTOR � ` wS/ O �� Y�� W PHONE u <br /> • <br /> CONTRACTOR ADDRESS y CRYISTATE21P KQA f—S+C)'yR 9531 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITYISTATEJZIP C� <br /> LICENSE -57 C-61 . D-09 Other NUMBER 1� EXPIRATION DATE ✓ ` 27 <br /> BILLING PAKTY: i OWNER CONTRACTOR SUBCONTRACTORJCONSULTANT <br /> DOMESTIC WELL PL1NG:kTGeneral Minera/Coliform Bacteria(4391)/'..Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private `i 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 WORKew Well Replacement Well J Well Alteration/Modification Other <br /> . Monitoring Wells) #of wells 3 Soil Boring(s) tt of borings Geotechnical #of borings <br /> Out-Of-Service Well 7 Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement u Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method X <br /> Mud Rotary Air Rotary Auger Cable Tool Push Point I Other <br /> Proposed Well Depth2btl _ft Excavation in diameter Open Bottom 2lGravel Pack/Gravel Size in diameter <br /> Conduct Casing in diameter / Conductor Casing Depth ( ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched� L I I, Steel JQ�Plastic ;Stainless Steel Other <br /> Grout Seal Depth10C ft Neal Cement(94 Ib bagl5-10 gal wafer) Li Sand Cement sack mix17 gal water <br /> xBentonite(20%solids) Other <br /> Grout Placemen(tt__Method Pumped �Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal '.DI ensions:Width If Length ft Thick in <br /> Christy Box Stove Pipe <br /> PUMP :Submersible Turbine -Other HP Pump Set ft Standing Water Level ft <br /> 1 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 /> Mr= rn-)rr a_,�7."b'01=n _ .. _ 131 ACE C <br /> ALL(209)951-7697 <br /> SIGNE �TEV I 1 • DATE <br /> �F Y�FNT <br /> CFsV�0 <br /> qN �5 ?p2p <br /> �"QN/N N <br /> N�EPry <br /> gR A4 <br /> T <br /> DEPARTMENTUS ONLY <br /> 64 ASApplication Accepted ByData S �) Area S / 1 Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Dale ❑ WAIVER Received <br /> Soil Boring Inspectign By Date Constructed Well Depth ft <br /> COMMENTS L-_ t� )e) iJ 'L"041r 65 r11'4L1 fill, lj )I <br /> PE SC Received he Amount D Perrnitl Invoice# Well ID# <br /> Codes Info sh Remitted ce <br /> F., O 4do <br /> 43G I j ISO 1 Q} <br /> y3 470 <br /> EHD 43-06 6!112019 WELL/PUMP PERMIT <br />