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ca <br />0 <br />a <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT WWW.S ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS .zotpcs E Ayers Ave_ orozip Bad On t e1552.0 <br />CROSS STREET \k:A.XA 9-6 APN 206 061 0 3't PARCEL SIZE • LAND USE APPLICATION it <br />OWNER NAME -6-An2ta I eihr, tActy- 1—tinne. TV_ <br />OWNER ADDRESS ACC 2.9Jk Q43..vrt Cm/STA-mate 6<SO-A Din I 96 32-0 <br /> pHoNUCcOlgb2, —S1Va I <br />SUBCONTRACTOR/CONSULTANT t4C1ç A R.. <br />SUBCONTRACTOR/CONSULTANT ADDRESS VSIFI <br />LICENSE /C-57 C-61 0-09 Other NUMBE/149:3 LA5 EXPIRATION DATE16_111Sackp <br />BILLING PARTY: J OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPUNG: .- General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private XlmigatiorJAgricultural Industrial <br /> Water Quality Monitoring Soil Sampling/Characterization <br />PHONE <br />CONTRACTOR <br />CONTRACTOR ADDRESS Fn• iLADX l J CITY/STATE/ZIP 50,11, oef 9S -.1 210 <br />PHONE t4 /19. <br />Crrr/STATE/Zle N1 t <br />Public Water System <br />otterent from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK 1 New Well Replacement Well <br />Monitoring Well(s) C of wells <br />Out-Of-Service Well <br />New Pump Pump Replacement <br />Well Alteration/Modification Other <br />Soil Boring(s) C ol twnngs Geotechnical <br /> of borings <br />Out-Of-Service Well Renewal Cross-Connection Repair <br />Pump Repair Raise Well Casing <br />WELL C0NSTRUC11 N <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Well Casing <br /> <br />Diameter .5 in Thickness/Gauge/ASTM Sched •250 XSteel Plastic Stainless Steel Other <br /> <br />Conductor Casing in diameter / Conductor Casing Depth It <br />sack mtx.17 gal water Sand Cement Grout Seal Depth ft Neat Cement (94 lb bag/5-10 gal water) <br />Bentonite (20% solids) Other <br />Retardant / Accelerator (name) <br /> <br />Grout Placement Method Pumped Free Fall Other <br />Installed By Driller )Pump Contractor Other PEDESTAL <br /> <br />_.Concrete Pedestal Dimensions: Width t G ft Length 12.- ft Thick Ls.:i in Christy Box Stove Pipe <br /> <br />HP 5 Pump Set '1.10 ft Standing Water Level X Submersible Turbine Other PUMP <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 46TIVE Wmi.,T11CAUFORNjfreoNTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATI <br />QUIRED FOR INSPEC TIONS - PLEASE CALL (209) 953- 697 <br />TITLE \11 • c) • DATE 6 n 1 21 <br />7z-e <br /> (,) ,d <br />SIGNED <br /> ( <br />INi• J <br />DEPARTMENT USE ONLY <br /> Date s el <br />Date <br />Date 5 tJ z. <br />Date <br />Area Litt i4;:i Employee 109 (7; <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br /> ft <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection Bya01.1S".. <br />Soil Boring Inspoction By <br />COMMENTS iiNh. IL Vrki-- F o II I7(1k; <br />PE <br />Codes <br />SC <br />Into <br />Received Checkati <br />Cash <br />Amount <br />Remitted Date Permit/ <br />Servic, Request 8 Invoice fl Well Irta <br />93 E%-) o :-.: I <br />dff9_ <br />146A-- 41 -4.)7 GI le4111 Rif 00406i <br />EHO 03-06 6:11;2019 WELL 'PUMP PERMIT