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WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 952D5.6232(209)468.3420 <br /> NON-REFUNDABLE PERMIT `_ / M/WW.S�gov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS /a �'V• t LSI CITYfZIP 'ZV (AWL <br /> CROSS STREET �+ S' APN JJCI VJ v0 4 <br /> PARCEL SIZE �I LAND USE APPLI A710N# <br /> OWNER NAME �'I y— PHOA10 - ✓—?V C) N <br /> OWNER ADDRESS CITY/STATFJZIP�� <br /> CONTRACTOR r�if. I j PHONE <br /> CONTRACTOR ADDRESS PZ) 8, 144 L. V, CITYISTATE/ZIP I LlJ V LT.�0 <br /> SUBCONTRACTORICONSULTANT t `I W PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITYL/.S(TAATE/ZI�P�-1 f I <br /> LICENSE XC-57 C-51 D-09 Other NUMBER I L) 1 ` W�PIRATgN ci <br /> DATE ` l U <br /> j BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOWCONSULTANT <br /> DOMESTIC WELL SAMPLING: General MineraliCohform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Dornestic/Pnvate rigation/Agncultural Industrial Water Quality Monitoring Soil SamplirglCharactenzation <br /> Public Water System <br /> If 40pemil from 0— WMer SYn"m N— C-­Name or Pian"lv n.r <br /> TYPE OF WORK New Well Replacement Well C Well AlterauonlModificalion -Other <br /> -- Monitoring Well(s) #of wells D Soil Bodng(s; "Oft-9s Geotechnical s or nonoys <br /> Out-Of-Service Well C Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump '1 Pump Replacement J Pump Repair _.Raise Well Casing _ <br /> WELL CONSTRUCTION 1, <br /> Drilling Method�-\Mud R a+ry, Air Rotary --Auger able Tool �.;Push Point Other <br /> Proposed Well Depth �/v it Excavation�in diameter _Open Bottom Gravel Pack'Gravel Sae In diameter <br /> Ccuc r Casing in diameler I Conductor Casing Depth ry <br /> Well Casing Diameter I TMiiccKness/Gauge/ASTM Sche Zk Steel >(Plastic :.Stainless Steel -Other <br /> Grout Seal Depth Q`e- -Neal Cement(94 Ib bag/5-70 gal water) Sand Cement sack mix/7 gal water <br /> >Tenlonite(20%Solids) .-Other <br /> j Grout Placement Method .Pumped -Free Fall Other Retardant I Accelerator(name) <br /> PEDESTAL Installed By -Driller ump Contractor - Other <br /> Concrete Pedestal-.Dimensions Width it Length R Thick in Christy Box - Stove Plpe <br /> !PUMP _:Submersible:Turbine Other HP Pump Set it Standing Water Level it l <br /> II? <br /> CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS- I ALSO CERTIFY THAT MV 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 /> 11INIMUh4 U ADVANCE/NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9 3-7 97 /l <br /> SIGNED / �� TITLE �rI �I'y"I DATE �v <br /> I I <br /> h'ECF VNT <br /> - - U� �8 2020 <br /> Ecou 7. <br /> I01VR 771,, <br /> I <br /> I <br /> L # <br /> DEPARTMENT 4SE ONLY <br /> Application Accepted By � Date n /7�43'J Area ���� Employee IDI �K <br /> Grout Inspection By A. �"-�'� Dale I 1 t t-�L�' SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Baring Inspection By ate Constructed Well Depth�ft <br /> COM ENTS D I <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cas Remitted Service R uest to <br /> i <br /> EHJ43LA yttaotg WELL IMIAIP PERMIT <br /> Z /J �- <br /> f <br />