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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 s. ov.org/ehd I EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSLo CITY/21P L <br /> CROSS STREET �— (/ �-DVO' '�'` D <br /> APN ARCEL$IZ . LAND USE APPLICATION# <br /> 0 <br /> OWNER NAME <br /> PHON _ r A <br /> -D H <br /> N <br /> OWNER ADDRESS s4o CITY/STATE/ZIP Q, <br /> CONTRACTOR PHONE ( D'nn/�1 �Ja 2/O <br /> CONTRACTOR ADDRESSCITY/STATE/LP <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS �'I/WRTATErZJP ,^} <br /> LICENSE -57 - C-61 _ D-09 Other NUMBER- EXPIRATION DATE <br /> BILLING P TY: OWNER ,.CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SA LING:..General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)_Arsenic(4393) <br /> INTENDED USE Domestic/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 New Well Replacement Well Well Alteration/Modification Other <br /> MonitoringWell(s) #of wells SOilBOdng(s) #ofbonngs Geotechnical #ofbodngs <br /> Out-Of-Servic Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum um Replacement Pum Re air Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary .Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement <br /> sack mixt)gal water <br /> Bentonite(20°h solids) _ Other <br /> Grout Placement Method Pumped Free Fall Other _Retardant/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 <br /> HP Pump Set=It Standing Water Level ft <br /> I HEREBY CE TIFY 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 /> CURREAND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORK S OMPENS O S. <br /> MI <br /> SIGNED C REQUIRED FO NS ONS-PLEASE CALL(209),,W-7697 <br /> TITL DATE <br /> J <br /> � 2021 <br /> UIN�0 <br /> N <br /> U <br /> r IVMFy q <br /> 7Y <br /> EPARTMENT USy ON Y /� <br /> Application Accepted By Date Z-/ Area I <br /> Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date I WAIVER RQCBIVed <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received eck# Amount Permit/ <br /> Codes Info B S Remitted Date Invoice If Well 10# <br /> O ce Re Lest# <br /> EMD 43-00" 6/112019 <br /> WELL/PUMP PERMIT <br />