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0 - <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 186E EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS F[�EX.PII Sr11 YEAR <br /> /FFROOM DATE ISSUED <br /> JOBADDRESS S (�. CITY/ZIP W e�7 4.i\ • J�J qy I <br /> I <br /> on <br /> I� I� D <br /> CROSS STREET AP `Z 1,Oq'01 PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME dlg 1 G'' PHONE .7.2 J 7 ryn <br /> OWNER ADDRESS C en CITY/STATE/ZIP ErT a Ift d/N CN- <br /> CONTRACTOR !Z 191C. It' C PHONE <br /> CONTRACTOR ADDRESS 1300 teVeIV CIN/STATE/ZIP 7(/.,e OC C_ /-J 00 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP �{ <br /> LICENSE (.2'57 C-61 D-09 Other NUMBER /3 7 2!f EXPIRATION DATE J'J/^ 21 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE &eSmestic/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 4,ftrewWell 4-fM-placement 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 Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION��// <br /> Drilling Method �,ifvtud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth1*d ft e Excavation�A in diameter Open Bottom L_—Gravel Pack/Gravel Size in diameter <br /> -. <br /> Conductor Casing___in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad JDR 2l Steel _44estic Stainless Steel Other <br /> Grout Seal Depth ?_D OF ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> en onite(20%solids) Other <br /> Grout Placement Method owl"6mped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Coofer <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP 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 /> JOAQUINCO TY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT A ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS C MPENSATION LAWS. <br /> MIIM V NCE NOTICE REQUIRED FOR INSPECTIONS-,PLEASE CALL(209)953-76697 <br /> SIGNED Ili TITLDATE <br /> MENT <br /> EIVED <br /> 19 2019 <br /> UIN COUNTY <br /> ONMENTAL <br /> DEPARTMENT <br /> D P RENT USE/�O �L/Y <br /> Application Accepted By ate 1��% l% Area Employee ID# <br /> Grout Inspection By Date_ G Well Permit <br /> Pump Inspection By Date r' WAIVER Received <br /> Soil Boring Ins action By Date Constructed Well Depth ft <br /> C M N S <br /> G � <br /> PE Sc Received Check#/ Amount Permit/ (�1/ <br /> Code I fo B Cash Eternitted Date Sfgyice R Invoice# Well ID# <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />