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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 NON-REFUNDABLE PERMIT www.sjgov.orgiehd EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 9 Li&zi E.()e i kwond Rd cmdzip 113 a_a5_21....T____ CROSS STREET "A A PN / fr.- I 41d ..--2.,(ARCEL SIZE et -VIAND USE APPLICATION # <br />OWNER NAME SI.ejj-e- So/PIA PHONE <br />I 4:1 4/62 1-1 E: (--'q k Woad gd ciTyisTATEIzip --frbck,-1--O r-I, (.4- <br />ADDRESS :SSMOCIV 2116 'i152'5 CONTRACTOR CONTRACTOR 1,400vman's uoct-kx s j WArns 1 nc. PHONE 209- 931-3210 CONTRACTOR ADDRESS .1(2-C) (_A.) i c <br />CITY/STATE/ZIP SIOCkfrfil C",- 95 2 45- SUBCONTRACTOR/CONSULTANT <br /> <br />CITY/STATE/ZIP <br />LICENSE C-57 _ C-61 _ D-09 _ Other NUMBER LidAT/14, BILLING PARTY: OWNER )(CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />EXPIRATION DATE 1/31/2 3 <br />PHONE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE X Domestic/Private _ Irrigation/Agricultural - Industrial - Water Quality Monitoring - Soil Sampling/Characterization Public Water System <br />If different from Owner <br />Contact Name or Phone Number <br />- New Well Replacement Well Well Alteration/Modification , Other <br />Monitoring Well(s) ft of wells Soil Boring(s) *of borings _ Geotechnical Out-Of-Service Well - Out-Of-Service Well Renewal _ Cross-Connection Repair <br />WELL CONSTRUCTION <br />_ New Pump Pump Replacement )(Pump Repair . Raise Well Casing <br />Drilling Method Mud Rotary _ Air Rotary _ Auger Cable Tool _ Push Point Other Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched _ Steel Plastic - Stainless Steel Other Grout Seal Depth It - Neat Cement (94 lb bag/5-10 gal water) <br />Bentonite (20% solids) . Other <br />Grout Placement Method Pumped -- Free Fall <br />PEDESTAL Installed By Driller Pump Contractor Other _ Concrete Pedestal _Dimensions: Width ft Length <br />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 WORKERS COMP NSATION LAWS. <br />MINI <br />DATE 4(1.42 <br />1:2 <br />Water System Name <br />TYPE OF WORK <br /># of borings <br />in diameter <br />Sand Cement sack mix/7 gal water <br />Other _ Retardant / Accelerator (name) <br />!Pump Submersible _ Turbine - Other HP Pump Set <br />ft Thick in Christy Box . Stove Pipe <br />E NOTICE REQUIRED FOROPECTIONS - PLEASE CALL (209) 957697 <br /> TITLE <br />1 <br />SIGNED <br />Lor <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS \\Sa\/\ \C-) <br />SA <br />H N E EA <br />(AD <br />PA TMENT U E OJrJLY <br />610 <br />Area <br />Employee ID*Allgolirde4A181 <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />r D TE <br /> Date <br />41 A lit JAI Is IF, late <br />DateDate ft <br />PE SC <br />Cod s Info <br />Recei ed Check//t <br />Cash <br />Amount <br />Remitted Date , <br />Permit/ <br />Sgvice Request # Invoice # Well ID# J7' -o es 10b0 4-77 1 *it <br />4 <br />kV 00L-11111-fl <br />END 43-06 6/112019 <br />WELL /PUMP PERMIT