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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95206 -6232 (209) 468-3420 <br />ADDRESS <br />C� <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />CITY/ZIP sl _ _ Y1 . ` J CPAS_ <br />CROSS STREET flnLvizAPN <br />C 9 0 PARCEL SIZE 7's <br />LAND USE APPLICCAATION ## <br />OWNER NAME i 1i d �"Dit!�(,n <br />i -kJ o`,lQlJl�lt,� <br />PHONE !/- <br />/31 - 0.6 <br />c <br />OWNERADDRESS _ p�Lltl� <br />CITY/STATE/ZIP_ <br />L20 <br />S C%(JYtf 'qr-a <br />/ <br />,S`� 1�J <br />CONTRACTOR MOOTIMCLYIS <br />1Q.iZ ID _ (i9_N <br />Wa4fir j�V J Inc <br />2Sa/S <br />x- 3CD/& <br />CONTRACTOR ADDRESS 2 120 �- <br />/Slis <br />�, � <br />CPHONE_?-Oq- <br />S-bc -hn, <br />CA- 95a1s <br />t a)C CITY/STATE/ZIP <br />SUBCONTRACTOR/CONSULTANT <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CITY/STATE/ZIP <br />LICENSE XC -57 ❑ C-61 ❑ D-09 ❑ Other NUMBER q (0 X 1?169 <br />ExPiRATION DATE <br />1 J > 1 /a S <br />BILLING PARTY: ❑ OWNER <br />❑ CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE ,pDomestic/Private , :rrigation/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 D Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Borings) u of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump # Pump Replacement ❑ Pump Repair ❑ Raise Well Casino <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 Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 /b bag/5-90 gal water) ❑ Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall D Other ❑ Retardant /Accelerator (name) <br />PEDESTAL Installed By ❑ Driller D Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length It Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP A Submersible ❑ Turbine ❑ Other HP= Pump Set I 2M it Standing Water Level /a :�_ 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 />m <br />D <br />0 <br />X <br />N <br />uJ <br />PAYMENT <br />RECEIVED <br />MAIC 0 2 2021 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />DEPARTMENT USE ONLY Cp <br />Application Accepted By _7� [J Z_ Date �/� d I Area l C� Employee ID# I 1`- <br />Grout Inspection By 0 Date /J ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />ft <br />PE SC Received <br />Codes Info B <br />Check#/ <br />Cash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />o5 d <br />1&0 SZ <br />7 2 z <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />