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4 <br /> ` WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 96206-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS !—O L CrrYfTJP Lodi' 95,25/2 m <br /> CROSS STREET `'/� --AP N��„� SZ�lJ-1 D3 PARCEL SIZE / V /LAND USE APPLICATION# �7 /� A <br /> OWNER NAME �QYL -\/eri-N- PHONE 2—Q ! (�Q�^O T/�/VI3� N <br /> OWNER ADDRESS O �. CIN/STATEMP� 1.1 !, zK2— <br /> CONTRACTOR p I I I c. PHONE z o q- 9,3/-21-7 <br /> CONTRACTOR ADDRESS 2-120 W I 1 ox 12d, CITY/STATE/ZIP 5 jxkj�o, C+'F521 - <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATEMP <br /> LICENSE Ij(C-57 D C-61 0 D-09 C Other NUMBER 46 f9( EXPIRATION DATE <br /> BILLING PARTY: ❑OWNER y CONTRACTOR C SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)G Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE D Domestic/Private 0 Irrigation/Agricultural D Industrial 0 Water Quality Monitoring D Soil Sampling/Characterization <br /> D Public Water System <br /> If different from Omer. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK C New Well C Replacement Well 0 Well Alteration/Modification 0 Other <br /> C Monitoring Wells) #of wells 0 Soil Boring(s) #of borings C Geotechnical If or borings <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump A Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool D Push Point 0 Other <br /> Proposed Well Depth ft Excavation in diameter C Open Bottom O Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad 0 Steel 0 Plastic 0 Stainless Steel C Other <br /> Grout Seal Depth ft u Neat Cement(94 lb bagl5-10 gal water) Cl Sand Cement sack mixl7 gal water <br /> C Bentonite(20%solids) Other <br /> Grout Placement Method D Pumped u Free Fall ::)Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor C Other <br /> 0 Concrete Pedestal❑Dimensions:Width ft Length it Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP SubmersibleD Turbine D Other HP I 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. 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. <br /> MINI '�/ R yCCEEfNNOOTTIIJICt�EREQUIRED FOR IN PECjT/IIOON�S-PLEASE CALL(209)953A69 <br /> SIGNED /�� /f �j !"/:///!� TITLE%Z�irLY'�L D �/ <br /> V 4— <br /> RECAWNT <br /> EIVEp <br /> SAY444 1 11 11 11 11 <br /> 1 Q 101 <br /> UIN COUNTY <br /> DEPARTMENT USE ONLY C ��NME('1(ry��L <br /> Application Accepted By L L Date S /�` ) Area Employee ID#DA �" 11 <br /> GroutInspection By Date D SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted rvlce R uest# <br /> $ oSa 7 VIC01) H-701.4 <br /> VV —Wt <br /> EH043-06 61112019 WELL(PUMP PERMIT <br />