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WELL/PUMP PERMIT <br />SARJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS �/ Ib 06 N�/. /`MAIN S�r,d a CITY//ZIP Mdt 4l'Ua 174"-?34CROSS STREET /V/C/,1 ,;.x '. ,1R// rM APN 7 /A - OCID - DSI PARCEL SIZE -I. 0 6 AVCAND USE APPLICATION # <br />OWNER NAME _ L. 4I l e A1'to PHONE <br />OWNER ADDRESS 13(61 .T, YIAr{D Ayt CITY/STATE/ZIP 10A S4"FrrMdJCD CA 10 'f-vig <br />CONTRACTOR kIj4dII <br />'�. (f"; PHONE /Z 11 q' 14L y& 111 <br />CONTRACTOR ADDRESS Z2(n� 'L'�. 1,r�1 �c.K CITY/STATEILP S�cG� /1 ✓� , G� `�11 ,0O <br />SUBCONTRACTOR/CONSULTANT WC1LT (dtl�' pFIT•�G PHONE [�Z OA S� ���� 7571 <br />SUBCONTRACTOR/CONSULTANT ADDRESS PD /�X ��� CITY/STATE/ZIP &,441k Ti�A 95320 <br />LICENSE X C-57 ❑ C-61 ❑ D-09 I I Other NUMBER 8 -r -h 7 ( EXPIRATION DATE 113 //202 2 <br />BILLING PARTY: .OWNER 'CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General MineraVColiform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE D Domestic/Private L Irrigation/Agricultural i Industrial D Water Quality Monitoring14 Soil Samplinp/Characterization <br />Public Water System W i%f' let /'20f 1 y'a - 62zs <br />If different from Ov err. Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well AlterationtModification G Other <br />Monitoring. Well(s) # of wells pr Soil Boring(s) 6 # of borings X Geotechnical # of borings <br />�i Out -Of -Service Well ❑ Out -Of -Service Well Renewal - Cross -Connection Repair <br />C New Pum � Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method r Mud Rotary - Air Rotary g Auger - Cable Toot - Push Point a Other <br />Proposed Well Depth /i It Excavation in diameter ❑ Open Bottom - Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad .: Steel : Plastic Stainless Steel - Other <br />Grout Seal Depth /C ft X Neat Cement (94 Ib bag15-10 gal water) L Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) - Other <br />Grout Placement Method C Pumped G Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By C Driller LI Pump Contractor E Other <br />❑ Concrete Pedestal CDimensions: Width ft Length ft Thick in - Christy Box �] Stove Pipe <br />PUMP I I Submersible::: Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br />1 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 />M IMUM 48 HD64MVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED ((�� <br />/ TITLE w C 0 . 11,, e e Ill' DATE <br />/ DEPARTMENT USE ONLY <br />Application Accepted By j-1 LI Date S L a I <br />Grout Inspection By Date <br />Pump Inspection By nnDate <br />Soil Boring Inspection Bye f/ Date <br />COMMENTS <br />Area 3 yl 1eCG', Employee ID# A �7 <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth _ <br />PE <br />Codes <br />SC Received Chec <br />Info B as <br />Amount Date Permitt Invoice # Well ID# <br />Remitted pervice Re ues <br />�137d <br />Iso <br />15a� <br />EHD 43-06 6/112019 WELL /PUMP PERMIT <br />