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Yt <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NUN-KEFUNDABLE t'ERMIT <br />JOB ADDRESS /'7/0/ <br />J'� <br />CROSS STREET vc.%� �/ <br />OWNER NAME tI C✓ /� <br />n <br />OWNER ADDRESS J /�•� <br />CONTRACTOR koCONTRACTOR ADDRESS <br />WWW.SIgOV. <br />APN _(D <br />z s'ar <br />r )6k ZZ <br />tXl'IK11=5 1 YEAR FROM DATE ISSUED <br />CITY/ZIP <br />SIZE—LAND USE APPLICATION #, <br />PHONE 9z6 W ( S 07- <br />CITY/STATE/ZIP - <br />CITY/STATE/ZIP <br />,+PHONE <br />/% / CITY/STATE/ZIP <br />SUBCONTRACTOR/CONSULTANT /L?©(�j ZIA* / (*' ��,� PHONE-- <br />SUBCONTRACTOR/CONSULTANT <br />HONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE ❑ C-57 <br />BILLING PARTY <br />❑ C-61 ❑ D-09 <br />❑ OWNER <br />❑ Other <br />CITY/STATE/ZIP <br />NUMBER 7 % 3Rr EXPIRATION DATE V 1_7 <br />❑ SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: AGeneral Mineral/Coliform Bacteria (4391)X Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: <br />Water System Name <br />Contact Name or Phone Number <br />TYPE OF WORK�IVew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />/❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ O t -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />lew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method �'1�ilud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />ProposedWeI Depth;�20 ft Excavation 1'2—- in diameter ❑ Open Bottom �ravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth )0`1' <br />ft c� <br />Well Casing Diameter _611� in Thickness/Gauge/ASTM Sched —)_Qc? 11Steel )Pelastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth 4'-1 i ft ❑ Neat Cement (94 Ib bag15-10 gal water) .D.6and Cement sack mix/7 gal water <br />❑ Bentonite ( % solids) ❑ Other <br />Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By XDriller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width_ ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP %ubmersible❑ Turbine ❑ Other H P= 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 />MINI U 48,11-110R ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697�I <br />SIGNED /1.� TITLE O�A41- DATE Z.1--1—/ /cO 2j <br />SAN JOAQUIN COUNTY <br />DEPARTMENT USE ONLY DCf <br />ENVIRONMENTAL � N�>� <br />Application Accepted By Date 16110.2 ,17 U G1 HFI� <br />I0;0 Area ! <br />Grout Inspection By ., Date 12 21 202a SPECIAL Well Permit <br />Pump Inspection By `kr ,j,'. W"i Date tti N li Lk WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS SeGon� vJe). /evrari <br />m <br />D <br />O <br />O <br />rn <br />m <br />PE SC Received <br />Codes Info B <br />Check#/ Amount Date <br />Cash Remitted <br />Permit/ Invoice # <br />Service Request <br />Well ID# <br />IsC <br />0 ZLA <br />w3� ►8� <br />oW <br />0041Z <br />43q <br />Isco <br />2 <br />Ga <br />-AD i <br />EHD 43-06 6/11/2019 ✓ WELL /PUMP PERMIT <br />