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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 />NON-REFUNDABLE PERMIT <br />www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS O F • o <br />CITY21P <br />M n <br />CROSS STREET !`y`'1 V t� 1� / 2, - ♦( <br />[� <br />T Q �'I� PARCEL SIZE J I O LAN. USE APPLICATION # <br />' `y� <br />5C) <br />p `APN <br />f� Q .'{ 9 <br />R0 9 —�' 7 v / —✓ � • <br />OWNER NAME ' `6<f- I <br />106e:3 E. Co lhir <br />4dj--,(- <br />_ _ !^• /PHONE <br />�+j C 9saa �- <br />OWNER ADDRESS <br />lam' <br />CITYISTATEILP �1,em YI <br />CONTRACTOR K oo rm ants Q <br />a�e.Sy s'k'Ns <br />PHONE OL e) 9 — /31-� _11 C) <br />CONTRACTOR ADDRESS 5LI• a o W I ICOR <br />j <br />I'(Z d. <br />� <br />` <br />CITYISTATEP� hr)., C4 a iS- <br />Z <br />SUBCONTRACTORICONSULTANT <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CITY/STATEIZIP <br />LICENSE AC -57 0 C-61 D D-09 <br />❑ Other <br />? ^� <br />NUMBER 414088/10 EXPIRATIONDATE <br />BILLING PARTY: ❑ OWNER <br />❑ CONTRACTOR <br />G SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) G Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE a DomesticlPrivate D Irrigation/Agricultural D Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization <br />0 Public Water System <br />['different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK O New Well 0 Replacement Well D Well Alteration/Modification 0 Other <br />C Monitoring Well(s) #of wells O SoilBoring(s) aOfborings D Geotechnical #of borings <br />C Out -Of -Service Well D Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />New <br />)rilling Method ❑ Mud Rotary D Air Rotary ❑ Auger ❑ Cable Tool D Push Point 0 Other <br />-roposed Well Depth ft Excavation in diameter C Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />D Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad C Steel G Plastic 0 Stainless Steel C Other <br />Grout Seal Depth ft 0 Neat Cement (94 lb bag/5-10 gal water) 0 Sand Cement sack mix17 gal water <br />C Bentonite (20% solids) ❑ Other <br />3rout Placement Method 0 Pumped D Free Fail 0 Other C Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller D Pump Contractor 0 Other <br />C Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in D Christy Box D Stove Pipe <br />PUMP A Submersible❑ Turbine ❑ Other HP Pump Set Kms' 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 COMP NSATION LAWS. <br />MIN M HM ADVANCE NOTICE REQUIRED FOR INSPE VIO�NS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE DATE <br />P RTMENT <br />Application Accepted By Data Il <br />Grout Inspection By Date _ <br />Pump Inspection By a G br' bY' JyV)', el' Date _ <br />Soil Boring lIn'spection By Date _ <br />Yf <br />COMMENTS OAAt +yw_,aw /'t 1/<I auZ $S ta <br />I� Employee ID#�_ ! <br />SPECIAL Well Permit <br />WAIVER Received <br />ted Well Depth ft <br />i���:Yl%f�/ii%Illy � + G�'ifi7��'" 11 ''ftL'f►•�� <br />EH04346 61110079 WELL /PUMP PERMIT <br />EIVED <br />2 2 2021 <br />ENTAL HEALTH <br />/SERVICES <br />PAYMENT <br />RECEIVED <br />LIAR 2 2 2021 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />4"5 <br />