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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 w .Sjgov.org/ehd on EXPIRES 'I YEAR FROM DATE ISSUED <br /> � <br /> JOB ADDRESS 1,25 111Pr- �/l�yC///�I CITY/ZIP c4 g15aa m <br /> CROSS STREET J U&4 APN 0a1 '9&C)/ —PARCEL USE APPLICATION#PARCELSIZE� D <br /> /� o <br /> /may -`_ 9 � <br /> OWNER NAME �^ D Im HONE /- 5���� <br /> ��/'(/�J23 _ "' / m <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> i <br /> CONTRACTOR A2X PHONE <br /> CONTRACTOR ADDRESS .!CO CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT ' PHONE + 1p 69113—l <br /> SUBCONTRACTOR/CONSULTANT ADDRESS /zq awxln C Y/STATE/ZIP <br /> LICENSE IAC-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE / V/, <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 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 ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)(Mud Rota�rryy� ❑ Air Rotary ❑ Auger ❑ Cable Tool 11 Push Point ❑ Other J <br /> Proposed Well Depth 3W ft Excavation �[r ? in diameter 11 Open Bottom Gravel Pack/Gravel Size �&diameter <br /> Ll Conductor Casing L in diameter / Cond for Casing Depth ft <br /> Well Casing Diameter SU in Thickness/Gauge/ASTM Sched ❑ Steel 'Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth /iD ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller I Pump Contractor, ❑ Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width ft Lengthft Thick in El Christy Box ❑ Stove Pipe <br /> PUMP XSubmersibleo 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 /> CURREAND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORK RS COMPENSATION LAWS. <br /> MI1 UM DV NCE NOTICE REQUIRED FOR INSPECT! NS -PLEASE CALL (209) -769 <br /> SIGNED /TITLE OA- DATE 67 U <br /> ty <br /> C <br /> \// C <br /> DEPARTMENT USE ONLY �Ep'gRTTq� <br /> MFNT <br /> Application Accepted By G� Date e dy .,7Jo70 Area L411 y Employee ID# DA <br /> Grout Inspection By, hA 11 4&V Date 0. 2:0 21CV-0 ❑ SPECIAL Well Permit <br /> Pump Inspection By �r1%/.L ��� e 8�,, Date fJ' ❑ WAIVER Received <br /> Soil Boring Ins ection By Date Constructed W 11 Depth ft <br /> COMMENTS O ✓� i D Iq <br /> Ali N7 <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> 14 Fa W- �►.�a �. w <br /> y N 1 �s 0 o�l 1 <br /> L \ <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />