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WELUPUMP PERI, <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST MAZEL70N AVENUE - STOCKTON CA 95205 -6232 (209) 468J420 <br />NON-REFUNDABLE PERMIT www.sjqov.cra1ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />FO-6DDRESS 3Dnca1 1/a<G(Ctrr2tP S-�-� 1b r\J j S Za(eROSS STREET W LI/a SH I NC,"tj �. ' A,, I q !�� C) � / PARCEL SIZE _LAND USE APPLICATION <br />(OWNER NAME C I T -Y Al!F .7 7y C' ---T0 � PHONE Cz O9% 937 ^�[Zyj Z' <br />OWNER ADDRESS / / 6 LD O /2/.I- <br />00 SI- CRY/STATE%ZP � G le- %a A� CA { J <br />CONTRACTOR 7-K"- Co I 'I ri� T) IZ.) LL.) 1J Cr / W G p <br />� PHQNE jSSy1 27l•"' 00617 <br />CONTRACTOR ADDRESS q61[3� 1 D G /'�J I 10,Q s T' C"STATErLP S/a U fI /fGv . C'/4 '7Z'1 Z 6 <br />SUBCONTRACTOR/CONSULTANT `' T )�1� &-f /r1 DT GO /t1LtZ-VS I)) O N .S �P �C/ !i L/j�1 HE L�%AIO� S y �/ - Z,7 Z <br />SUBCONTRAC <br />�TO <br />`R/CONSULTANT ADDRESS83! / wl U+Mrf&5 HIJLj� Cff�Y//STATE2�IP�7r-'��� <br />iLICENSE *" -57 F C-61 �-1 D-09 Otter NUMBER 5 / 77✓ / FXPIRATIOM DATE /30 ZZ- <br />IBILLING PARTY: ❑ OWNER fl CONTRACTOR ] SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Colitorm Bacteria (4391) ❑ DibromochiOropropane (4392) L; Arsenic (4393) <br />INTENDaO UsE C Domesfic/Private D IITfgatlon/Agncuttural L Industrial ❑ Watar Quarrty Monitoring Soil Sampling/Characterization I I <br />Public Water System <br />If different hom Omer alar System Narra Contact Name or cne Number <br />TYPE OF WORK I New Well ! Replacement Well i Weil Aftera5on/Modification +•Other G/aT71 /G G7 70 �U <br />Monitoring Wells) # of wells t Soil Boring(s) # of bmrgs Geotechnical # of bonnie <br />Out -Of -Service Well - Out-OfServlce Well Renewaf i I Cross -Connection Repair <br />7 New Pump 2 Pump Replacement G Pump Repair ^ Raise Well Casing <br />IWcu r <br />rifling Method * Mud Rotary 3 Air Rotary C Auger D Cable Tool C Push Point M Other <br />roposed Well Depth _�1 ft Excavation /Z In diameter C Open Bottom L Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth it <br />Well Casing Diameter _ In Thickness/Gauge/ASTM Sched r Ski ! plastic 7 Stal Iess Stee,'3l i Other <br />Grout Seat Depth ZO RC Neat Cement (94 /b beg/5-10 gal water) L'Iand Cement��., sack mixt) gal water <br />-1 Bentonite (20% solids) -1 Other <br />out Placement Method WPumped -1 Free Fall -1 Other -1 Retardant / Accelerator [namel <br />EDESTAL Installed By C Driller f_ Pump Contractor C Other <br />Concrete Pedestal CDfinenslons: Width _ ft Length ft Thick in C Christy Box C Stove Plpe <br />PUMP C Submersible C Turbine C Other HP Pump Set 11 Standing Water Level h <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. 1 <br />hiljNl/1M�L�L`?J38. HO 1ANCE NOTICE REQUIRED FOR INSPPECC.iI,UNS - PLEASE CALL J209) 9553. 697 <br />/61' ! / <br />SIGNED ✓V „'�� TITLE 0104Q /11 f f"'4 N'Of UATE <br />Application Accepted By/ <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />/ <br />--`�-� <br />DEPARTMENT USE ONLY <br />Data % % aJl I <br />Date '}' ii <br />Date _ <br />Date <br />-- <br />Area •' Employee ID# /r f <br />ODSSPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth R <br />PE mw ved <br />Codes Info <br />he <br />sh <br />Amount Perml <br />Remitted Da a Service Re uest # Invoice # Wall ID# <br />EHD 43-06 611172019 <br />iz711�7� <br />WELL 7PlRAP PERMIT <br />LA <br />P <br />J/N <br />;NFN�UNTY <br />'4RT/NENt <br />