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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-KEFUULNDABBLE PE//R(M'IIT� WWW.S ov.or /ena t1CPIKtb T YEAR FROM DATE ISSUE <br />JOB ADDR0SS� %• Oa�I) 1r.�� S �/ �y� / CITY/ZIP T rar- b1 gs.377 <br />CROSS STREET �.I-o�Y 1 }�(W7 APN Z(/-1 �y03 PARCEL SIZELAND USE APPLICATION# <br />OWNER NAME [Q,IC7(' �S L. rQ } PHONE <br />OWNER ADDRESS CRY/STATEfE Q9 <br />rZ'P� 10 <br />(�� <br />CONTRACTORrd •1 <br />e e/ PHONE . <br />, Ct S <br />CONTRACTOR ADDRESS I r r JI/ LV CITY/STATEIZIP / <br />SUBCONTRACTOR/CONSULTANT UG/ PHONCZP -7700 <br />SUBCONTRACTOR/CONSULTANT ADDRESS I Elac1- CnY/STATEIZIP cpqlf ,yr 3Z <br />LICENSE ,/ C-57 r C-61 ❑ D-09 -1 Other NUMBER 00 EXPIRATION DATE I O V - <br />BILLING PARTY: ❑ OWNER CONTRACTOR 7 SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE E Domestic/Private ❑ Irrigation/Agricultural E Industrial ❑ Water Quality Monitoring Soil Sampling/Characterization <br />:1 Public Water System <br />If different from Omer: Water System Name Contact Name or Phone Number <br />TYPE OF WORK i New Well I i Replacement Well I Well Aiteration/Modification i i Other <br />-1 Monitoring Well(s) # of wells r- Soil Boring(s) # of borings Geotechnical a of borings <br />i Out -Of -Service Well L Out -Of -Service Well Renewal L Cross -Connection Repair <br />j New rump -i rump KepiacemenT u rump Kepair a masse vveu casing <br />WELL CONSTRUCTION ,/ <br />Drilling Method :1 Mud Rotary ❑ Air Rotary +tp Auger ❑ Cable Tool 7 Push Point ❑ Other <br />Proposed Well Depths 30 ft Excavation in diameter C Open Bottom C Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thlckn�esls/Gauge/ASTM Sched E Steel C Plastic :1 Stainless Steel ❑ Other <br />Grout Seal Depth ft Nr Neat Cement (94 Ib bag/5-10 gal water) C Sand Cement sack mix/7 gal water <br />-1 Bentonite (20% solids) n Other <br />Grout Placement Method Vf Pumped j Free Fall -1 Other Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller C Pump Contractor ❑ Other <br />7 Concrete Pedestal ❑Dimensions: Width It Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP 7 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 />DEPARTMENT US (ONLY <br />Application Accepted By Date off/ Area Jr Employee ID#� <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By gate Constructs] Well Depth ft <br />COMMENTS -:rfC'UQV .4et eY1La3t1 4'YP-el 6rrke pr c6,j -?V Ake- Pls�ie <br />- I - n A- -2-0. R—o i <br />MMITMEW.R.i"tll� <br />/r9iiiil� <br />EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />NT <br />'ED <br />2021 <br />:OUNTY <br />NTAL <br />iTMENT <br />