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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 />NUN-KEFUNDABLE PERMIT <br />tAl'IKtJ 7 T EAK ?RUM UA It: ISSULU <br />Joe ADDRESS vi -fl I IV9 I 1 I UYVIL-\L(ACA L41. CrrY/LP / Js <br />T <br />CROSS STREET Vah rq�Y h7T APN Dbj-� V� PARCEL SIZE -���- LAND USE APPUCAT10N# <br />OWNER NAME (/� WII ( �� PHONE / uA (' ^ <br />OWNER ADDRESS 6 (� C-('IlI YC�f !. C' CITY/STATE(LP -1 ./ - `I ` z �� ly O� <br />CONTRACTOR I 1 PHONE �-`� r-^ -71 1 <br />CONTRACTOR ADDRESS CITY/STATE/ZIP I-ra 56 �O <br />V <br />TRACTOR/CONSULTANT PHONE <br />TRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP -''/ <br />C-57 C -fit D-09 Other NUMBER 3O3 EXPIRATION DATE /�31-i� <br />PARTY: - OWNER y CONTRACTOR -. SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPUNG: %- General Mineral/Coliform Bacteria (4391) . Dibromochloropropane (4392) -i Arsenic (4393) <br />INTENDED USE Domesbr/Private i-: Irrigation/.Agricultural - Industrial Li Water Quality Monitoring Soil Sampling/Charactenzation <br />Public Water System <br />If dinerem from Owner: Wafer System Name Comaot Name or Phone Number <br />TYPE OF WORK New Well Replacement Well r Well Alleration/Madificabon Other <br />Monitoring Well(s) # of wells ❑ Soil Bonng(s) s of bOnnva Geotechnical a of borne' <br />Out -Of -Service Well ❑ Out -Of -Service Well Renewal LCross-Connection Repair <br />V New Pump PUmD Reolacement PumD Reoair - Raise Well Casino <br />Drilling Method `� Mud Rotary "- Air Rotary - Auger Cable Tool Push Point Other <br />Proposed Well Depth):ej �)_It Excavation �` in diameter Open Bottom )( Gravel PaddGravel Size in diameter <br />:. Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameterj,�2 in Thidmess/Gauge/ASTM Sched �/►s4n - Steel � Plastic Stainless Steel Other <br />Grout Seal Depth_ft [i Neat Cement (94 lb bag/5-10 gal water) X Sand Cement3 sack mix/7 gal water <br />:. Bentonite (20% solids) C Other <br />Grout Placement Method Pumped ..7 Free Fall I Other Retardant / Accelerator (name) <br />IPEDESTAL Installed By XDriller ❑ Pump Contractor Other <br />Concrete Pedestal ;Dlmenslons: Width a ft Length it Thick in - Christy Box '.. Stove Pipe <br />PUMP j,Submersible Turbine = Other HP Pump Set tt 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 />MINIMUM 8HOUwnR ADVANCE NOTICE REQUIRED FOR INSPECTIONS.- PLEA§E CALL (209) 953-7699j7 <br />SIGNED ;�' /l GL-4'b4�Cr` TITLE V i '6 pros id ren 1 DATE <br />DEPARTMENT USE ONLY <br />Application Accepted By f Date z vZ" 0 Area I cl Employee ID# NGrout Inspection By Date ❑ SPECIAL Well Perm(t <br />Pump Inspection By . I 'i Dale ❑ WAIVER Received <br />�j <br />Soil Boring Insgpdion By I Rate, _ Constructed Well Depth (� 4 It <br />RFY,EN <br />cF� SFO <br />oZ 3,9 <br />r/RON /N CO <br />y�Ep FNTa QTY <br />EHD 43-'9 6/11/2019 v I 1 <br />WELL (PUMP PERMIT <br />(�W4 P / 7f2,5:� ri #1118�573l <br />