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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 NON-REFUNDABLE PERMIT v.^.....v.sjgov.orglehd EXPIRES 1 YEAR FROM DATE ISSUED <br />crryizip <br />CROSS STREET <br />CITY/STATE/ZIP <br />NUMBER <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT <br />R, SUBCONTRACT /1 , / CONSULTANT ADDRESS <br />LICENSE C-57 C-61 0-09 Other <br />BILLING PARTY: OWNER <br />OWNER NAME m /Mad 1-17.)d, <br />OWNER ADDRESS :5454.5 F # _ <br />CONTRACTOR 1Y1,001/111a/P73 / <br />CONTRACTOR ADDRESS 2/20 bo/coy <br />JOB ADDRESS <br />tkdova <br />AVA- <br />_ CONTRACTOR <br />CitE S—C/0°3 PARCEL SIZE III 9 LAND USE APPUCATION <br />PHONFC?W9. 1/Ei. qi <br />CITY/STATE/ZIP 671Z:e.,/f<22.‘'i 614 47,5?7R <br />PHONE 207/ <br />CITY/STATE/ZIP 674-1VCW2 (i/4 <br />PHONE <br />EXPIRATION DATE <br />_VAKba SS31100V MIS DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) _ Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural - Industrial Water Quality Monitoring 7 Soil Sampling/Characterization Public Water System <br />',different from Owner: <br />Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) #01 borings Geotechnical Out-Of-Service II Out-Of-Service Well Renewal _ Cross-Connection Repair New Pump Pump Replacement Pump Repair I Raise Well Casing WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched <br />Grout Seal Depth ft - Neat Cement (94 lb bag/5-10 gal water) <br />Bentonite (20% solids) Other <br />Grout Placement Method - Pumped Free Fall - Other <br />PUMP <br /> 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 WORKERS COMPENSATION LAWS. <br />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />Water System Name <br />#t borings <br />PEDESTAL Installed By Driller Pump Contractor _ Other <br />Concrete Pedestal _ Dimensions: Width ft Length <br />y Submersible _ Turbine Other <br />ft Thick in • Christy Box _ Stove Pipe <br />HP Pump Set <br />_ Retardant / Accelerator (name) <br />_ Steel Plastic Stainless Steel Other <br />- Sand Cement sack mix/7 gal water <br /> ft Standing Water Level <br />in diameter <br />SIGNED <br />TITLE DATE <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By Z.— Date <br />Date SPECIAL Well Permit <br /> <br />Grout Inspection By <br /> <br /> <br />Pump Inspection By Date 5/2 L0021 WAIVER Received <br /> <br />Soil Boring Inspection By <br />Constructed Well Depth ft COMMENTS <br />Date <br />Area La iq Employee ID# <br />pAYrofitioNT <br />RE E <br />SAN <br />T <br />MANI i <br />ENV RO EN <br />Qu COUNTY <br /> <br />2.CT \ <br />HEALTH Oh; ARIMENT <br />PE <br />Codes <br />(-13s1 <br />Invoice # <br />END 43.06 6/112019 <br />WELL /PUMP PERMIT <br />0S-0 <br />SC <br />Info <br />Received Chec <br />ash <br />6/6‘' <br />Amount <br />Remitted <br />"7 <br />Date <br />(r112'1 <br />Permit/ <br />writtR4ru5,)__ <br />Well ID#