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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 <br /> NON-REFUNDABLE PERMIT v..S OV.O /ehd MEXPIRES 1 YEAR FROM <br /> DATE ISSUED <br /> JOB ADDRESS > t C./ZIP <br /> Y a <br /> CROSS STREET��a'S' �Q�IC APN U S -550 I�PARCEL SIZE I.I� LAND USES APPLICATION 9 o <br /> OWNER NAME V r GZ PHONE / Qhun Z� o? <br /> �~ `�W—� <br /> 1 �� 10anh b <br /> OWNER ADDRESS I"1 CITY/STATE/ZIP Q GCG CA <br /> CONTRACTOR ft_vN, , PHONE <br /> CONTRACTOR ADDRESS AAjRaCITY/STATE/ZIP m o d s-4a <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/Y/S <br /> STTATE/ZIP <br /> LICENSE 57 C-61 D-09 Other NUMBER •V23 ExPIRATION DATE <br /> BILLING PAR Y: OWNER CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)XP <br /> 4391) ibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE omesti Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If drfferent from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well D Well Alteration/Modification C Other <br /> MonitoringWell(s) #of wells ❑Soil Boring(s) #of borings Geotechnical rt of borings <br /> Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> New Pump Pump Replacement ❑Pump Repair -1 Raise Well Casing <br /> WELL CONSTCTION <br /> Drilling Method Mud Rota -i Air Rotary ❑Auger Cable Tool Push Point Other <br /> Proposed Well Depthft Excavation 1'2_ in diameter Open Bottom ravel Pack/Gravel Size N6,L in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter__L in Thickness/Gauge/ASTM Sche 9.2-1 Steel lastic Stainless Steel Other <br /> Grout Seal Depth 2_01)_ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> ?<J`ento ite 20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By DrillerPump Contractor Other <br /> Concrete Pedestal DI ensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP C Submersible Turbine Other HP Pump Set ft Standing Water Level 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. 1 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 REQUIR INSPE TIONS-PLEASE CALL(209)953-t7�697 <br /> SIGNED E F DATE lo <br /> I VC U1 <br /> vT <br /> V/ <br /> NTy <br /> A TMENT US <br /> El N L Y TMFNT <br /> Application Accepted By „ ate Area Employee ID# C���rCfIJ�' <br /> Grout Inspection B Date �� SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received �� <br /> Soil Boring Inspection By Date Constructed Well Depth �((27� ft <br /> COMMENTS 't:S <br /> PE SC Received C ec Amount ate Permit/ Invoice# Well IDS <br /> Codes I B ash Remitted Senvice Re uest# <br /> rr <br /> EHD43-06 6/1112019 WELL/PUMP PERMIT <br />