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1.4 OLL.J I <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDA E PERMIT www.,sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS + ' _ CITY/ IP / c( m <br /> X11` (Zol 5 i 7UZ �k <br /> t CROSS STREET Y j V 1 � PARCELSIZE. f LAND USE APPLICATION# A <br /> //�, VU <br /> m <br /> OWNER NAME Wn v, _ PHONE �(n <br /> OWNER ADDRESS CITY STATEIZIP 5 te to- <br /> CONTRACTOR ^' �/✓6 , J c/ b y/n y s gilt h PHONE <br /> CONTRACTOR ADDRESS c7V I�J` y//��i/��l�'I/� I�� CITY/STATE �/ �_�Q <br /> SUBCONTRACTOR/CONSULTANT IY / t PHONE 1 J /-1 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS / CITY/STATE/ZIP <br /> /VIA <br /> t <br /> LICENSE _ C-57 rl C-61 _ D-09 Li Other 0 Uj NUM�EI�7 W W 1, EXPIRATION DAT12 -3 ��v <br /> BILLING PARTY: OWNER F1 CONTRACTOR 1 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: a General Mineral/Coliforrn Bacteria (4391) - Dibromochloropropane(4392)Cl Arsenic(4393) <br /> rINTENDED USE omestic/Private ❑ Irrigation/Agricultural _ Industrial _ Water Quality Monitoring _. Soil Sampling/Characterization <br /> I� _ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well '.i Replacement Well LI Well Alteration/Modification -i Other <br /> - Monitoring Well(s) #of wells n Soil Boring(s) #of borings - Geotechnical PA Er <br /> Out-Of-Service Well u Out-Of-Service Well Renewal a Cross-Connection Repair ITt(�E(1 V <br /> --= New Pump Pump Replacement ❑ Pump Repair C Raise Well Casing '=D <br /> WELL CONSTRUCTION J "` 2 V 2021 <br /> Drilling Method _ Mud Rotary a Air Rotary a Auger _ Cable Tool L Push Point _. Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom L Gravel Pack/ r QU�IN meter <br /> _ Conductor Casing_ YN ENTAL_in diameter / Conductor Casing Depth ft HEALTH DEPARTMENT <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched -i Steel a Plastic _ Stainless Steel ❑ Other -,N <br /> Grout Seal Depth ft n Neat Cement(94 Ib bag/5-10 gat water) Ll Sand Cement sack mix/7 gal water <br /> - Bentonite(20%solids) 3 Other_ <br /> Grout Placement Method - Pumped n Free Fall 5 Other F1 Retardant/Accelerator(name) <br /> PEDESTAL— Installed By - Driller ❑ Pump Contractor C Other <br /> _ Concrete Pedestal❑Dimensions:Width ft Length ft Thick- in _ Christy Box L Stove Pipe <br /> LPUMP Subrnersible- Turbine Fl Other HP Pump Set ft Standing Water Leve 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 /> MINIMUM 48 HOUR ADVANCE (NOTICE REQUIRED F ;��I/ /SPEC;�TyI�O/NSr/�1-PLEASE CALL (2109) 53-7697 <br /> SIGNED , TITLE 1 l�l.�ll_ � I DATE <br /> _ _ r <br /> 1--I-- I - - - —-T <br /> }-- -� - �- <br /> tt� t <br /> I <br /> I l l l l l l l l l l l l l l l l 1 .1 l l <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date-y'76/"71 Area y liC, Employee ID# Fk <br /> Grout Inspection By Date C SPECIAL Well Permit <br /> Pump Inspection By �rt Z t Date 2� (( / Z` I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chec Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Re uest# Invoice# Well ID# <br /> €�a OSP �7 21 2 p I <br /> EHD 43-06 6/11/2019 <br /> WELL/PUMP PERMIT <br />