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WE�,L��f�Mw�P PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209)'468-3420 <br />NON-REFUNDABLE PERMIT WWV1l.S;� OV.Or /ehd EX RES 1 YEAR FROM DATE ISSUED <br />. ,, r, n_ p <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDF <br />SUBCONTRACTOR/C <br />��/ t%�{'b I� � CITY/ZIP % �!`, <br />� APN O � � � � SO PARCEL SIZE/�^ELAND USE APPLICATION # <br />( /CJ/'' I ��C (� �`Z.� PHONE L Z�� f f�� <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE �-57 ❑ C-61 ❑ D-09 <br />BILLING PARTY: ❑OWNER <br />CITY/STATE/ZIP <br />❑ Other NUMBER S� / ��S EXPIRATION DATE <br />❑ CONTRACTOR ❑SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLINGeneral Mineral/Coliform Bacteria (4391) <br />INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial <br />❑ Public Water System <br />If different from Owner: Water System Name <br />TYPE OF WORK <br />�Dibromochloropropane (4392) ❑Arsenic (4393) <br />❑ Water Quality Monitoring ❑Soil Sampling/Characterization <br />Contact Name or Phone Number <br />`New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br />❑ Monitoring Wells) # of wells ❑Soil Borings) # of borings ❑Geotechnical <br />❑ Out -Of -Service Well ❑out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />mew Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br />WELL CONSTRUCTION <br /># of borings <br />Drilling Method �lud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other I i <br />Proposed Well Depth�ft Excavation � in diameter ❑Open BottoM Gravel Pack/Gravel Size o in diameter <br />❑ Conducto Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter � in Thickness/Gauge/ASTM Sched � O� ❑Steel jf,�Plastic ❑Stainless Steel ❑Other <br />Grout Seal Depth Z, OO ft ❑Neat Cement (94 Ib bag/5-10 gal water) ��Sand Cement�� sack mix/7 gal water <br />❑ Bentonite (20%solids) ❑Other j` <br />Grout Placement Method ;Pumped ❑Free Fall ❑Other ❑Retardant /Accelerator (name) <br />PEDESTAL Installed By <br />riller ❑Pump Contracto <br />��, <br />❑ <br />Other <br />Amount <br />Remitted <br />Date <br />❑ Concrete <br />Pedestal ❑Dimensions: Width <br />ft <br />Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP �JCSubmersibte❑ 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�IM 48eH�Ol�R ADVANCE NOTICE REQUIRED FO�R�I"N�S/P�ECTIONS -PLEASE CALL (209) 953-7697 <br />SIGNED ��i �� � ,�� TITLE (/{i(!/y6�'�- DATE __ <br />s <br />DEPARTMENT USE ONLY <br />Application Accepted By Liv Date 7 �% a0o717 <br />Grout Inspection By �!'G-t�L:S Ca V'PNio{.�� Date �1D� <br />Pump Inspection By Date <br />Area � � Employee ID# �� <br />❑ SPECIAL Well Permit <br />❑ WAIVER ReCeiVetl <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS �io�P�}�� SOJ'�I'1WC's�' �IG� pi�)'s ,n tele porf�. �� �y►��i�h 1S`O" feet s�o�r�rfior� f{ate'+ <br />q I) Pr �'S of sPo�l� grecrs �',/��*l7an .� �xw � <br />T <br />-i <br />m <br />D <br />v <br />0 <br />;o <br />m <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />ec <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Re uest # <br />Invoice # <br />Well ID# <br />y3$c� <br />es � <br />-� I sa <br />21.10 <br />0�-[ <br />y366 <br />,ga <br />LIa� <br />�� �1•Zv <br />�.I�oo�i�t't <br />3 I <br />J�-c� <br />��l•Z��Z� <br />W$t� 0 � <br />�13 <br />� 70 <br />� . 21.y� <br />0 <br />- - „ <br />EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />