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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -8232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.siaov.ora/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS Lr <br />J • I V V <br />%. CITYIZIP <br />I `+ <br />] <br />CROSS STREET <br />O • PARCEL SIZE' LAND <br />USE APPLICATION ft <br />iAPN <br />J <br />Pve <br />/ �j <br />4 10L .5 <br />OWNER NAME ; <br />• <br />PHONE r <br />v <br />OWNER ADDRESS • . QX <br />n <br />4v Q <br />CDYISTATERIPR <br />/ <br />1 Q 0�. CR 01 S �(p( <br />{. � <br />CONTRACTOR <br />C• <br />PHO �) y ` 59 <br />CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />SUBCONTRACTORICONSULTANT <br />PHONE <br />SUBCONTRACTORICONSULTANT ADDRES <br />CITY/STATEMP <br />LICENSEC-57 C-61 <br />D-09 :: Other <br />NUMBER Z 1/S10 ) <br />EXPIRATION DATE �/ �•�+ <br />BILLING PARTTY:: :OWNER <br />CONTRACTOR <br />G SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING:. General Mineral/Coliform Bacteria (4391) G Dibromochloropropane (4392) _. Arsenic (4393) <br />INTENDED USE xDomeslic/Private Irrigation/Agricultural Industrial i ; Water Quality Monitoring Soil SamplingiCharacterization <br />'ublic Water System <br />If different from 0v Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well D Well Alteration/Modification Other <br />Monitoring ell(s) # of wells O Soil Borings) sof borings _ Geotechnical <br />Out -Of -Service Well D Out -Of -Service Well Renewal Cross -Connection Repair <br />N of borings <br />WELL CONSTRUCTIONTT�����t""" <br />Drilling Method�ud Rotary Air Rotary Auger Cable Tool Push Point 71r— <br />Proposed <br />t r <br />Proposed Well Depth �ft Excavation -1 2 in diameter Open Bottom Gravel Pack/Gravel Size � • in diameter <br />Conductor Casing in diameter / Conductor CaSoqjDppth ft <br />Well Casing Diameter __UL in Thickness/Gauge/ASTM Sched Steel . lasfic Stainless Steel Other <br />Grout Seal D/epth�0ft Neat Cement (94 Ib ba9/5-10 gal water) Sand Cement sack mix/7 gal water <br />" <br />Aentonite 0% solids) Other <br />Grout Placement Metho umped Free Fall Other Retardant /Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal D e Ions: Width ft Length It Thick in Christy Box Stove Pipe <br />PUMP .: Submersible. Turbine Other HP Pump Set It Standing Water Level ft <br />1 HEREBY CERTIFY THAT 1 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 />MINIMUM 48 HOUR. ADVANCE NOTICE QUI INSPECTIONS - PLEASE CALL (209)(9953-76971) <br />SIGNE TITLE i ,. T. DATE _ a —2-A <br />PA <br />CF�VJUN <br />�,® <br />Ty pp"OROlM"N CO <br />t 7-yP <br />EP,ARTMENT USE O LY <br />Application Accepted ByLli"4'Date � . ` <br />4-1 <br />I <br />Grout Inspection By '-t Date Q <br />Pump Inspection By Date <br />Soil Boring <br />COMMENTS <br />Amount <br />Info <br />Dale <br />Permit/ <br />q Aiti Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />ructed Well D�pth ft <br />Invoice # Well ID# <br />IM <br />a <br />EHD 43-06 6/11/2019 /( 103 272—j WELL/PUMP PERMIT <br />