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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.sjgov.orq1ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSCITY21P •�v m <br /> ^^ J� ] 7 D <br /> CROSS STREET APN V rl 7;0O O / PARCEL SIZE r �O LAND USE APPLICATION# p <br /> OWNER NAME PHONE O N <br /> OWNERADDRESS V V �Q/�Vs 1��K CITY/STATE/ZJ n <br /> CONTRACTOR l Cox <br /> PHONE ,2-6 C!/ <br /> Wakllr 511j, Inc. - - 9`71-�35W <br /> CONTRACTOR ADDRESS ZI Z �`1 o , W1 Co c( CITY/STATE/ZIP �kh I,(4 9sa/s <br /> SUBCONTRACTOR/CONSULTANT h 1 14 PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISSSTT�ATEErZIP <br /> LICENSE {4(C-57 ❑C-61 ❑D-09 ❑Other NUMBER q tl�110 EXPIRATION DATE fh�3 <br /> BILLING PARITY:: ❑OWNER it CONTRACTOR D SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:G General Mineral/Coliform Bacteria(4391)_-,Dibromochloropropane(4392)E Arsenic(4393) <br /> INTENDED USE VDomestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 7 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> 0 Monitoring Wells) #ofwells ❑Soil Boring(s) #ofborings 0 Geotechnical -#of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> 0 New Pump X Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary ❑Auger 0 Cable Tool 0 Push Point 0 Other <br /> Proposed Well Depth ft Excavation in diameter 0 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 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth ft 0 Neat Cement(94 lb bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br /> 0 Bentonite(20%solids) 0 Other <br /> Grout Placement Method 0 Pumped 0 Free Fall 0 Other 7 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor ❑ Other <br /> 0 Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box 0 Stove Pipe <br /> PUMP %SubmersibleO Turbine 0 Other HP Pump Set ft Standing Water Level It <br /> 1 HEREBY CERTIFY THAT 1 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. 1 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 COOWENSATION LAWS. <br /> Mlgw OU CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953 67 <br /> SIGNED TITLE DATE z 2 <br /> v <br /> Ll I <br /> PAYMENT <br /> RECEIVED <br /> MAN 0 2 2021 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> DEPARTMENT USE ONLY /J HEALTH DEPARTMENT <br /> Application Accepted By Date 3/a a Area l Employee ID# F k <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date L./ Lil/ 4 ,/ ❑ 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 14 Rash Remitted ice Re uest# <br /> 3 0>o <br /> EHD 43-06 61112019 WELL/PUMP PERMIT <br />