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I, WELL/PUMP PERMIT <br />SAN JC/.\QUINtOUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />r <br />NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 11 YEAR FROM DATE ISSUED <br />JOB ADDRESS` \& CITY/ZIP YN <br />CROSS STREET APN PARCEL SIZE/jo LAND USE APPPPL'IICCATION#` <br />OWNER NAME Gc� PHONE7ZI-47— IO1 I S -7/ '7 <br />OWNER ADDRESS CITY/STATE/ZIP <br />CONTRACTOR X" �`S `J /PHO/NES 3 � �72_s <br />CONTRACTOR ADDRESS �" O CITY/STATE/ZIP [x/0.12 -e <br />JV <br />SUBCONTRACTOR/CONSULTANT Lt .L2 / ry7 %Z�.�S Sy%V✓J PHONE 7? 2,;7-3 1 <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br />LICENSE /Lf -t.-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 22�226r - EXPIRATION DATE <br />BILLING PARTY: ❑ OWNER ❑ CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING:XGeneral Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE )[ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characteriza�b� 'r <br />❑ Public Water System �� <br />If different from Owner: Water System Name Contact Name or Phone Number wIT U�^,n i <br />TYPE OF WORK >6(lew Well [I Replacement Well ❑ Well Alteration/Modification ❑ Other _ JOA I' <br /># of borings0 Geotechnical g /xl <br />0 Monitoring Well(s) # of wells 0 Soil Boring(s)�N7 <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair N DEPART HT <br />L9,New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />Drilling Method JM MIud Rotary ❑ Air Rotary ❑ Auger P Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth�ft Excavation / in diameter ❑ Open Bottom 4 -Gravel Pack/Gravel Size_' in diameter <br />❑ Condu r Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diamet r in Thickness/Gauge/ASTM Sched _ ❑ Steel S Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Deptft ❑ Neat Cement (94 lb bag/5-10 gal water) ><Sand Cement Z(913 sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Metho0dPumoed ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By 215,Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width. ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP ,jdf Submersible ❑ 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 />c <br />JU C f- H r[ I Iva G IN I U J G V IY L I <br />Application Accepted By `� �v � Date ^- y D Area �gCf Employee ID# bA <br />Grout Inspection By tWAqif "L ED Date to C ❑ SPECIAL Well Permit <br />Pump Inspection By Date E( 2-1�o2 ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />ft <br />A <br />m <br />D <br />0 <br />m <br />m <br />v, <br />G7 <br />EHD 43-06 6/11/2019 1 1 1 1 WELL /PUMP PERMIT <br />c��r���.-� <br />�. _ <br />�r��yc�mmJ��L•ni�rr�r� <br />EHD 43-06 6/11/2019 1 1 1 1 WELL /PUMP PERMIT <br />