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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 />www.slaov.ora/ena <br />JOB ADDRESS '#AN( /`yL CITY/ZIP /7 r../I /'IGt! <br />CROSS STREE4 Z 14 _ APN O O 00`</ PARCEL SIZE LAND USE APP�LICATIONf#� <br />OWNER NAME .iii G PHONE— O / �Z - _�L► <br />r� <br />OWNER ADDRESS CITYISTATE/ZIP <br />s (( C <br />CONTRACTOR /� FT v rLAs/'S PHO�Ny�E <br />CONTRACTOR ADDRESS / Y.y 17? CITYISTATE/ZIP <br />SUBCONTRACTOR/CONSULTANT /� tf ` �'`� S • – " I PHONE27� <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITYIST77ATEIZIP <br />LICENSE <C-57 0 C-61 ❑ D-09 El Other NUMBER37'%J(icy EXPIRATION DATE_ <br />BILLING PARTY: I I OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: I i General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392)1 Arsenic (4393) <br />NTENDED USE omestic/Private ❑ Irrigation/Agricultural a Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />rYPE Of- WORK ifPNeW Well EI ReDlacement Well II Well Alteration/Modification ❑ Other <br />rl Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical _ # of borings <br />EI Out -Of -Service Well ❑ Out -Of -Service Well Renewal Ci Cross -Connection Repair <br />2new rump u rump Kepiacemenr a rump Kepalr u Kaise vveit uasing <br />WELL CONSTRUCTION <br />Drilling Method,>eMud Rotary ❑ Air Rotary D Auger ❑ Cable Tool U Push Point ❑ Other <br />Proposed Well Depth00 ft Excavation LZ in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter <br />EI Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched2-7) U Steel %!-Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth c� ft U Neat Cement (94 Ib bag/5-10 gal water)Sand Cement LV sack mixl7 gal water <br />LI Bentonite (20% solids) U Other <br />Grout Placement MethodPKOPumped 13 Free Fall E1 Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By >i_4 Driller ❑ Pump Contractor U Other <br />CI Concrete Pedestal 17Dimensions: Width_ ft Length ft Thick in D Christy Box D Stove Pipe <br />Pump '-fiieSubmersibie❑ 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. 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 />F <br />MINIMUIIVV[ 48 HOUR,tDVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209).953-7697 <br />m <br />rn <br />0 <br />0 <br />0 <br />X <br />rn <br />N <br />IYI C IV I U J G V IV L 7 <br />Application Accepted By Date C.- <br />Grout Inspection B C' wVVL — Date <br />Pump Inspection By (a. �'•it+L Date <br />Soil Boring Inspection By _ Date <br />COMMENTS <br />Area_v Lt.- Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />•//• <br />,Tcnrf.1'1�111111111111111111111 <br />'' '• <br />Permit/ <br />!� qu <br />111 <br />fwmw <br />yam, <br />MT-noER/141FM <br />wYY� <br />� <br />� ml by <br />M �MARIMMIN <br />w -M <br />MWA <br />-Ar <br />Mi <br />I- • V, • L - rI _ - _ _ <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />