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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 />...... ' ..I_hA FYPIRFC 1 YFAD canRA nATF IcsuFn <br />JOB ADDRESS J 7 3� 9 C { t /� ey) � �J� CITY21P <br />CROSS STREET ✓rrte" " Y): "A � ' `V APN 0/ CI _;' ct 3� PARCEL SIZE 0LAND USE APPLICATION # <br />OWNER NAME Vf' n y)t S (7c PHONE <br />OWNER ADDRESS CITYISTATEILP / <br />CONTRACTOR �/ -� I[1jC 7 1` 1 n �1 PHONE A _1'_7 <br />—C�C� <br />CONTRACTOR ADDRESS I I J C' Y. CITY/STATE/LPG- NE <br />'\ 1 I\ ` -,\ C� 5 0_� <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/LP <br />LICENSE ?C �' <br />C-57 C-61 D-09 Other NUMBER 1�11 7 �J EXPIRATION DATE—7 <br />BILLING PARTY: OWNER CONTRACTOR 11 SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING:•!_1 General Mineral/Coliform Bacteria (4391) 11 Dibromochloropropane (4392) I i Arsenic (4393) <br />INTENDED USE ADomestiCtPdvate Irrigation/Agricultural i Industrial ❑ Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />It different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK 7( New Well Replacement Well ❑ Well Alteration/Modification Other <br />Monitoring Well(s) # of wells D Soil Bormg(s) If of b000as Geotechnical a of borings Mq <br />Out -Of -Service Well ❑ Out -Of -Service Well Renewal Cross -Connection Repair <br />ew Pum 1: Pump Replacement ❑ Pump Repair Raise Well Casing <br />WELL CONSTRUCTION L Ev A'V Q <br />Drilling Method�Mud Rotary Li Air Rotary LiAuger ❑ Cable Tool Push Point Other 7 ) <br />Proposed Well Depth 350 ft Excavation � in diameter Open Bottom /X Gravel Pack/Gravel Size lig in diame e <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched C ?'i i Steel KPlastic Stainless Steel Other <br />Grout Seal Depth (C �' It Neat Cement (941b bag/5-10 gal water) Sand Cement sack mixR gal water <br />Bentonite (20% solids) t'. Other <br />Grout Placement Method A Pumped J Free Fall I Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor, Other <br />)( Concrete Pedestal (Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />POMP Submersible I Turbine i Other HP�Pump Seteft Standing Water Level i 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 />4 4jF <br />vi <br />D <br />0 6 ?020 <br />?USN C <br />T4 L <br />gRTMENT <br />DEPARTMENT USE ONLY <br />ss 1 <br />�Jw `+ Cf� Si4'Yee <br />Date � <br />Application Accepted By Area Employee ID# <br />Grout Inspection By -� �✓� Date )tt ,,o ❑ SPECIAL Well Permit <br />Pump Inspection By Date V ❑ WAIVER Received <br />Soil Boring Ins ectiop By Date Constructed Well Depth ft <br />COMMENTS i"Je W k_)ir0 <br />EHD 43-06 6/112019 V v /' WELL /PUMP PERMIT <br />mN om <br />END <br />vFfjj=rFT,'#T <br />EHD 43-06 6/112019 V v /' WELL /PUMP PERMIT <br />