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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.sjgov.orglehd EXPIRES 1 YEAROMDATE ISSUED <br /> " <br /> JOB ADDRESS I C��� 'y } Q CITY/ZIP OC m <br /> CROSS STREQ APN / Cha Ll PARCEL SIZE •�� LAND USE APPLICATION# o <br /> F p/� ` z <br /> OWNER NAME r 1 ` PHONES L Z r��� N <br /> m <br /> OWNER ADDRESS X /� ��* CITY/STATE/ZIP // <br /> CONTRACTOR �X /�-�c�� Ll� 'PH/ONE 3 3 V— ' � <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP Z"(./ C)010491zlo A e <br /> SUBCONTRACTOR/CONSULTANT PHONE 22,;! '3 �G►lJ <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP` <br /> LICENSE �C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 7'2 3 J>T EXPIRATION DATEy ,3 <br /> BILLING PARTY: ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:X 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 /> -*4eW Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method"<Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well DepthI-W ft Excavation 12.- in diameter ❑ Open Bottom leGravel Pack/Gravel Size in diameter <br /> ❑ ConductojCasing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter•? in Thickness/Gauge/ASTM Sched ❑ Steel Plastic ❑ Stainle s Steel ❑ Other <br /> Grout Seal Depth-/AX)____ ft ❑ Neat Cement(94 Ib bag/5-10 gal water) 6and Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method AfPumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width Af ft Length=ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP .)eSubmersible❑ 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 COMPENSATION LAWS. <br /> MINIM 48 HO R AD ANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209)953-7697 <br /> SIGNED <br /> cr�C �— TITLE DATE l�' <br /> IN T-J <br /> DEPARTMENT USE ONLY 1 <br /> Application Accepted By ����� Date � Ws'` dO,cO Area ' Employee ID# !/ <br /> \YRIt.+ 14 �� �"1 npu ❑ SPECIAL Well <br /> Grout Inspection By ��5\� r '\. Date <br /> Pump Inspection By kI­G"n1�5110 k•` Date ❑ WAIVER Reca 41 <br /> Soil Boring Inspection By Date Constructed Well Depth �/�� ft <br /> COMMENTS fi/sf17! .( ; fPWc,rl '' 11 <br /> SAA, <br /> PE SC Received CnEk# Amount Date Permit/ Invy O ME/yT II # <br /> Codes Info B ash Remitted Service Request# D <br /> 11350 us C3 1so? 8 25 12 00 �\ � ror <br /> Ll� 1$0 Ou 1\ 0 <br /> N3� � ►Sc7 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />