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c. <br />Idarr <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDLI PERMITv . WWW.sjgov.org/ehd ,i-- EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS I 4.5 5 ° 0 - . crryiztlarcli 6 ci's3o14 <br />c bbi-eii-t&I; . AiaN a flool -W c-'E'L'ik , 13 ' LAND USE APPLICATION # <br />/la a) ri oehrte . 5 4-e4e OWNER NAME 9:0II lit 0.- <br />, <br />PHONE r35 .' 114i/ <br />OWNER ADDRESS 0-5btr/640-5, 3-6 g) -Plet4i St CITY/STATE P - 7 I . Ft' 1414-39q4 elq5A (%1 'Nal , t I <br />CONTRACTOR ADDRESS cl) 47 ft <br />AI 0 , Ps....i-vION c a <br />,x. Q CONTRACTOR -17-S La 1/Wi IA t n4 i 'Irk <br />E <br />SUBCONTRACTOR/CONSULTANT V <br /> 'L./ CITY/STATE/ZIP <br />nt/ PHONE ('/ <br />SUBCONTRACTOR/CONSULTANT ADDRESS A) 114 CITY/STATE/ZIP <br /> <br />EXPIRATION DATE 164 i 5 <br />zz <br />LICENSE _ C-57 VC-61 _ D-09 U Other 0 Z 1 NUMBER c21 C9(46 <br />in , ,,,,,. <br />BILLING PARTY: - OWNER Ver)NTRACTOR -1 SUBCONTRACTOR/CONSULTANT <br />Contact Name or Phone Nu lflynn <br />TYPE OF WORK New Well u Replacement Well Li Well Alteration/Modification J Other <br />E <br />- Monitoring Well(s) <br />_ Out-Of-Servic Well . .. U Out-Of-Service Well.Renewal LI Cross-Connection Repair J AN 2 8 I <br /># of Wells 11 Soil Boring(s) # of borings <br />. <br /> <br />- Geotechnical i R ECPII 4. <br />-# of bo-rints, La <br />2021 7 New Pump Pump Replacement 0 Pump Repair Raise Well Casing CAA A —A/ jo Am , <br />LN <br />, <br />, ENvip(EALTHDsju eNTAL y COuN4ivi •r 8 Dril(ing::Method ,._ Mud Rotary LI _AirRotary .........q,f\rger.. __Cable Tool 1,. Push Point _ Other rr <br />Proposed Well Depth ft Excavation in diameter :: Open Bottom L Gravel Pack/Gravel 'Si__ ' ..."'illi re': '''''' . ' . ., ' - ARTIVIVicrameter <br />Conductor Casing .in diameter / Conductor Casing Depth <br />Well Casing Diameter : - in . Thickness/Gauge/ASTM- 7 Sched - . . . • Steel J. Plastic _. Stainless Steel LI Other ,. . ., .- .. . . .• , ..... <br />Grout Seal Depth ft El Neat Cement (94 lb bag/5-1O gal water) Fl Sand Cement sack mix/7 gal water <br />7 Bentonite (20% solids) -I Other <br />Grout Placement Method - Pumped rl Free Fall Fl Other [I Retardant! Accelerator (name) <br />PEDESTAL Installed By I" Driller 0 Pump Contractor C Other <br />_ Concrete Pedestal liDimensions: Width ft Length ft Thick _ in _ Christy Box Li Stove Pipe <br />[pump ?<Submersible - Turbine n Other HP 2. Pump Set ft Standing Water Level C 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 REQURED 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 />MINIMUM 4 HOUR 'VANCE NOTiCE REOIARED F,INSPECT1ONS - PLEASE CALL (209) 913-7Q97 <br />-erna tr1W DATE / fq/Z 4 SIGNED TITLE 3 <br />II I I I I I I <br />DEPARTMENT USE ONLY <br />Application Accepted By Date ija Area Employee ID# <br />Grout Inspection By Date 0 SPECIAL Well Permit <br />Pump Inspection By crctilt. co Leovei\..rLL Date 2 iS/242. I CI WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received <br />BA <br />(ChecIA Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# -Ma <br />1-13g 1 o so d61-- ,343q1 477 19;7121 tAl oo to <br />Cn <br />rn <br />171 <br />07 cn <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Ii Arsenic (4393) <br /> <br />; INTENDED USE XDomestic/Private U Irrigation/Agricultural _ Industrial _ Water Quality Monitoring _ Soil Sampling/Characterization <br />_ Public Water System <br />If different from Owner: Water System Name <br />WELL CONSTRUCTION <br />1[111111111 <br />ft <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT