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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -6232 (209) 466.3420 <br />W IJr'J-ISEr UNDABLE PERMIT wVVvV.sjqov.org1ehd EXPIRES 1 YEAR FROM DATE ISSUE[ <br />JOB ADDRESS 7L93 L , �- dcj , n ven U f CITYIZIP MOD -Lec G I l �. -/ �-?37 <br />CROSS STREET , ' / ILt%�) e(T cA r�GQ C1 APN 1)..y /C. t PARCEL SIZE T, -A /LAND USE APPLICATION <br />M <br /># / <br />OWNER NAME 1111 Ch cie1 /11UTn-Lun PHONED 9,5337 <br />�� �7 <br />OWNER ADDRESS 7C,9 L=- . 61?dctn A Ve/iu,!t CITY/STATE/ZIP mart encci /C?d[� 1, 33 / <br />CONTRACTOR a-'I� �P mp j7Service, l�I I� L PHONE 4Y-�� '/%�1 I'O S ) <br />_q 9CONTRACTOR ADDRESS ,?f5 6 LJ IS 0)-) R(y ; (i/u S`e tj CITYISTATE/ZIPJ 1L4r )0C-- 1<�, CA <br />SUBCONTRACTORICONSULTANT Teler C9 , [(rr..-1/ Sco Ay � 1")Le'LLC ` PHONE Cdc I) 3���a 16 <br />SUBCONTRACTORICONSULTANT ADDRESS _ 36M a CITYISTATE/ZIP <br />LICENSE n C-57 'k C-61 n D-09 <br />BILLING PARTY: ❑ OWNER <br />-1 Other NUMBER ExPIRATION DATE <br />of CONTRACTOR 3 SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) O Arsenic (4393) <br />INTENDED USE ,)• Domestic/Private ❑ Irrigation/Agricultural C Industrial ❑ Water Quality Monitoring 7 Soil Sampling/Characterization /1 w <br />7 Public Water System H <br />It different from Owner. Water System Name Contact Name or Phone Number C <br />TYPE OF WORK i New Well I I Replacement Well I Well AlteralionlModification i I Other <br />-1rings <br />Monitoring Wellg#of burin <br />Well(s) # of r Soil Boring(s) 9s n #ofboGeotechnical AUG <br />J Out -Of -Service Well L Out -Of -Service Well Renewal U Cross -Connection Repair , <br />A New Pumo 7 PumD Reolacement n Pumn Renair r1 Raise Well Carina _ <br />""q Q UI <br />Drilling Method 7 Mud Rotary ❑ Air Rotary D Auger ❑ Cable Tool 7 Push Point D Other ENV/ <br />Proposed Well Depth ft Excavation in diameter C Open Bottom C Gravel Pack/Gravel Size ,� <br />&*ft"i <br />Conductor Casing in diameter / Conductor Casing Depth it <br />Well Casing Diameter _ In Thickness/Gauge/ASTM Sched C Steel C Plastic J Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 /b bag/5-10 gal wafer) C Sand Cement sack mixl7 gal water <br />-1 Bentonite (20% solids) n Other <br />1--0 PI --f RAMI,nd n P. --f l r— rill , Mk. ❑eh.rhnl I Anroro.ob., <br />PEDESTAL Installed By ❑ Driller C Pump Contractor ❑ Other <br />7 Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP 5[Submersible❑ Turbine ❑ Other HP .30C Pump Set Y Ci It Standing Water Level _�C it <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 />wn vaDcc me mc,Anna r -- <br />DEPARTMENT USE ONLY <br />�C <br />Application Accepted By 'Gj_ Z— Dale Vu�l3 Area 3 Employee ID# f <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By �i' yam— Date�41 - (i G, ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth it <br />COMMENTS <br />W <br />0 <br />N <br />� �E <br />T <br />D <br />2020 <br />'NTq� TY <br />�TMENT <br />M M IMF, MAN <br />FHD43.06 61112019 WELL(PUMP PERurT <br />FHD43.06 61112019 WELL(PUMP PERurT <br />