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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 465-3420 <br />NON-REFUNDABLE PERMIT www.sjgov.org/ehd Lodi, EXPIRES I YEAR FROM DATE ISSUED <br />JOB ADDRESS I s q 3II W_,Wf-r S0.C- CITY2C1P o I , <br />CROSS STREET C TC, y/b r APN 0 37 06 03 `� PARCEL SIZE 4'7e LAND USE APPLICATION # <br />SOWNER NAME L r 'PHONE Zoy�cj� �1 i— 3(j"7q <br />OWNER ADDRESS 15k4 31 N Lb i'�.rJt�CCITY/STATEIZIP WN I+ �/i 11-15-,W11-15-,W11-15-,Wa <br />CONTRACTOR I A on r m aril S `-ajw 5, • .�G 1" S Inc. PHONE 201— /01 —y 3-1Z I C) <br />CONTRACTOR ADDRESS L060 W\`-0`74 �N CIN/STATE/ZIP `7� <br />SUBCONTRACTORICONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATEIZIP <br />LICENSE y C-57 0 C-61 0 D-09 0 Other NUMBER qb d 61 l0 EXPIRATION DATE <br />BILLING PARTY: ❑ OWNER ❑ CONTRACTOR 0 SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) r_, Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE PLDomestic/Private 0 Irrigation/Agricultural C Industrial D Water Quality Monitoring 0 Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK C New Well D Replacement Well 0 Well Alteration/Modification 0 Other <br />C Monitoring Wells) # of wells C Soil Boring(s) # of borings 0 Geotechnical 0 of borings <br />C Out -Of -Service Well 0 Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />0 New Pumo 1 Pumo Reolacement 0 PUMD ReDair 0 Raise Well Casing <br />Drilling Method ❑ Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point C Other <br />Proposed Weft Depth ft Excavation in diameter C Open Bottom C Gravel Pack/Gravel Size in diameter <br />C Conductor Casing in diameter I Conductor Casing Depth It <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Sched C Steel u Plastic C Stainless Steel C Other <br />Grout Seal Depth ft 0 Neat Cement (94 lb bagl5-10 gal water) 0 Sand Cement sack mixl7 gal water <br />C Bentonite (20% solids) ❑ Other <br />Grout Placement Method C Pumped 0 Free Fall 0 Other C Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor D Other <br />0 Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in C Christy Box 0 Stove Pipe <br />PUMP Submersible Turbine 0 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 />MINI/Jr�JA/ <br />�, U CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953 69 . <br />SIGNED � 4 TITLE // � � DATE <br />DEPARTMENT U$E ¢NLY <br />Application Accepted By e��i� Date -� �q '7/ Area / Employee ID# / ✓ <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By DateS �!�Z l ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date Constructed Well Depth <br />EHD43-M 91112019 WELL!PUMP PERMIT <br />IIIIIIIIIIIIIIIIIP; M" <br />MMONXII11rnt�rr�rl�®mr►� <br />EHD43-M 91112019 WELL!PUMP PERMIT <br />