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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 PERMIT e Www.SJgov.Org/ena tXF'IKt5 9 YEAR FROM UATTE/ISSUED <br />JOB ADDRESS QUG3Cp� ��`1 ►q ,o . I". CITY/ZIP L?S_d0b <br />CROSS STREET 1 `� _A}P_ _ �p� 7 1 PARCEL SIZE ) rJ6- LAND USE APPLICATION # <br />OWNER NAME Fe -mJ)"'), L I T TP PHONE <br />_ (! 3 1 <br />OWNER ADDRESS S J E 1 rr CITY/STATE/ZIP Sel N305 P S/ /3':z <br />CONTRACTOR //��/ `i I PHONE / <br />CONTRACTOR ADDRESS o. A A- /6 ; CITY/STATE/ZIP Zed,, G lb 'r— -�' Z <br />SUBCONTRACTOR/CONSULTANT PHONE 70 7- 3 2- 7- 3i 7- <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br />LICENSE ;C-57 <br />BILLING PARTY: <br />❑ C-61 ❑ D-09 ❑ Other <br />OWNER <br />CONTRACTOR <br />NUMBER -9Ti / Z �) EXPIRATION DATE Z b LZ <br />SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) 1 Arsenic (4393) <br />INTENDED USE A Domestic/Private ❑ Irrigation/Agricultural ❑ 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 />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump 4 Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <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 />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTA Installed By I] Driller Li Pump Contractor 11 Other <br />■ Concrete Pedestal Li Dimensions: ■ Christy Box ■ Stove Pip <br />Lu- MP ■ Turbine ■ Other HP PumpLevel <br />WORKERS1 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 />• • <br />,�R ADVANCE NOTICE REQUIRED FOR 1��PECTIQ - PLEASE CALL (209) 953-7697 <br />SIGNEDie TITLE ll�ev-7,��� .. <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />AN <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■'i■�f■■■■■■ill■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■lid`■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />T <br />m <br />D <br />0 <br />v <br />m <br />m <br />V) <br />PE <br />Codes <br />SC <br />Info <br />Received Check#/ Amount Date Permit/ Invoice # Well ID# <br />B Cash Remitted Service a uest # <br />L3 1 <br />0_0I <br />- <br />A W IAI <br />EHD 43-06 6/11/2019 • " 24'VI-6' WELL /PUMP PERMIT <br />