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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 />NUN-KEFUNDABLE VE�RjMIIfT <br />WWW7".'S� <br />OV.or Iet1O <br />l TEAR FROM UATE ISSUED <br />JOB ADDRESS / � 7 / <br />( J <br />�1 <br />iRrN f -,ii / / W { %t i • V�_ CITYIZIP <br />Gt1AY1KtJ <br />CROSS STREET ` / *1e-" /t <br />APN <br />PARCEL SIZE a' Z r <br />LAND USE APPLICATION # <br />OWNER NAME CSI A 01 <br />4y.910 -CZ <br />Constructed Well Depth <br />PHONE ZO - y3o <br />-2 <br />OWNER ADDRESS I ] <br />/ <br />ev- Milli `- i,_ �1//� <br />p(� <br />LV CITY/STATE/ZIP^�Ti/L <br />4� <br />�✓(/��)���/ <br />CONTRACTOR ) <br />`Q <br />/_11111 #101 • N / w <br />_ _ _ <br />PHONE <br />�l <br />CONTRACTOR ADDRESS <br />• <br />CITY/STATE/ZIP <br />SUBCONTRACTORICONSULTANT <br />(/(/C,J7 �Q' TLJr/%/�Q <br />T/o�'�'S 1/ N C <br />PHONE ZO r '7� <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />�� 30 X ?3 <br />CITY/STATE/ZIP&& <br />7 7 <br />] <br />/V h 9� L7 L <br />LICENSE )(C-57 C-1511 <br />D-09 Other <br />NUMBER 8707& f <br />EXPIRATION DATE- <br />BILLING PARTY: OWNER CONTRACTOR <br />SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) 7N -107 ZI-t <br />INTENDED USE Domestic/Private Irrigation/Agncultural Industrial Water Quality Mona�o%r ng 7KSQlL$amplin !Characterization <br />Public Water System X40 rNwh ���N y� <br />II d,tte—i I— Owner. Watee System Name Contact Name o' Pone NumUor <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells XSoil Boring(s) Z u of Donn9s )r Geotechnical a of oonngs <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />'i <br />mdise vveii <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth15' ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter I Conductor Casing Depth h <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth /s ft h Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mixl7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall A Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set It Standing Water Level it <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 <br />WORKERS COMPENSATION LAWS. <br />MINIM HOUR A VA CE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 95 -7697 <br />SIGNED .�� i`H /%k H TITLE 111 1 ee. JVjQ / ✓/^ DATE G �/� / <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />D PA 'TMENT USE ONLY <br />n r <br />v Date ,1 <br />Area 1.-O� Employee ID# <br />Dale <br />SPECIAL Well Permit <br />Date <br />WAIVER Received <br />Date 150 y <br />Constructed Well Depth <br />ft <br />PE SC Received Check#/ Amount Permit/ <br />Codes Info By Cash Remitted pale SP rvice Request # Invoice # Well ID# <br />J/21 1 <br />/ <br />EHO4:1.06 6/112019 ew V : WELL,PUMP PERMIT <br />M <br />ANT <br />- <br />Ve6 <br />03 ?021 <br />