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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 /> NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1(0q dG/itOr)0 � --'('kf—l. �i� C/!S.�.ILL' CITYv <br /> ]� <br /> //�� J.73 a <br /> CROSS STREET --A16 /it�f T J("r �A/PN -,Z;2��y o i PARCEL SIZE _LAND USE APPLICATION <br /> OWNERNAME C()lr�lAi7i7/ //7/�lJc �4" /'I��JGL./ PHONE,)/Q!� <br /> 1 _ <br /> OWNER ADDRESS �,44, /�/y�J-2/12 CRYISTATE/ZJP /�� <br /> CONTRACTOR Grp// 1 L� �N rl l l�l7� Lin- TnI _ PHONE &)Cj �n1n1„ Ai 7- L <br /> CONTRACTOR ADDRESS �oo S 1,� 1 CITY/STATE/ZIP <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATE/ZIP <br /> LICENSE - C-57 C-61 - D-09 - Other NUMBER EXPIRATION DATE <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE 6ornestidPrivate - Imgation/Agricultural - Industrial _Water Quality Monitoring =Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. Water System Name Contact Name w Phone Number <br /> TYPE OF WORK eW Well Replacement Well _Well Alteration/Modification Other <br /> Monitoring Well(s) »of wells -Soil Bonng(s) a of borings Geotechnical :of borings <br /> Out-Of-Service Well -Out-Of-Service Well Renewal Cross-Connection Repair <br /> I/�ew Pum -- Pump Replacement -Pump Repair _ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Aud Rotary - Air Rotary _ Auger - Cable Tool " Push Point - Other <br /> Proposed Well Depth ft Excavation in diameter - Open Bottom - Gravel PacidGravel 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 Seat Depth ft = Neat Cement(94 lb bag15-10 gal water) - Sand Cement sack mixl7 gal water <br /> Bentonite(20%solids) -Other <br /> Grout Placement Method Pumped =Free Fall =Other _ Retardant I Accelerator(name) <br /> PEDESTAL Installed By Driller _ Pump Contractor _ Other <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 If <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 LAW <br /> NIMUM 4, HOUR AN CE NOTIIMREQUIRED INSPECTIONS-PLEASE CALL(209)953-7y697 <br /> SIGNED f JA L IIIf v TITLE <br /> \ DATE <br /> c----------------- - <br /> I TE# �i . <br /> F 'Iya N <br /> CpU <br /> -�J DEPARTMENT USE ONLY (Fp1"R A4 <br /> Application Accepted By /�' L `" Date Area / / Employee ID# '?I/rJ NT <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date=--`-1-'--�`-� WAIVER Received <br /> Soil Boring In pection ByDate Constructed Well Depth ft <br /> CO�MJMENTS tom' U <br /> PE Sc Received kQjGW Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Bv Cash Remitted Service nest# <br /> ' S � V✓ � <br /> EHD43-06 6/1112019 WELL[PUMP PERMIT <br />