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,1. <br /> , 1 <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST 14AZELTON AVENUE-STOCKTON CA 95205 6232(209)4683420 <br /> NON-REFUNDABLE PERMIT WWW.S OV.OT /elld EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> 31110 LV£S f /1,7 A 2 Gn L-/J N t£ I y <br /> cmrzlP 5 -D CK.-T o r� 5 z�1 9 i <br /> CROSS STREET R00 tG-SI,7 C R j7 APN I `/S(�l7�/^ .---- m <br /> / �/ C/ PARCEL SIZE 1 r I LAND USE APPLICATION# <br /> OWNER NAME `�I T i O <br /> 4F S'�GIGT'C)n) PHONE�Zoq) g37- �Z1Z � <br /> OWNER ADDRESS Z S Al �.,.�+y�- j�0 YL/�L D O �s 7" CmiSTATEMP S Ta GGe 7 0 4 C A g$' <br /> CONTRACTOR T�I - L- 1 / p 2..)L L) n!(y //VC PNONE 65% Z-71— 00C/? <br /> CONTRACTOR ADDRESS 3 J G /1J f 10,41 �fS''T' CrrY/STATEaP Ski IV 40/fGv. C',4 -Z/Z f <br /> SUBCONTRACTORICONSULTANT_ J )�jN�7//6N C0^ILr w,s})j0 rV ,S tl e �(}`�f SNE /0)S <br /> SUBCONTRAcroRR/CONSULTAMADDRESS &3/ 1 TVi"rO� THUG{ crrYlSTATErzIP MI" <br /> -f-4-5v`L`Cr <br /> LICENSE W1557 - C61 ,,D-09 -�Other NUMBER 5Y 77-37 EXPIRATION DATE a �ZZ- <br /> BILUMG PARTY: -m,OWNER D CONTRACTOR 7 SUBCONTRACTOR/CON$ULTANT <br /> Domunc WELL SAMPLING:0 general Mineral/Coliform Bacteria(4391)G Dibromochloropropane(4392)G Arsenic(4393) <br /> INTENDED USE i Domestic/Private �7 rrrigation/Agricultural C Industria! D Water Quality Monitoring =Soil Sampling/Characterization <br /> C Public Water System <br /> Mdh nt ham Owner Water yalem am• rttaq ame or erre Number <br /> TYPE OF WORN New Well Replacement WeU Wefl AflerationlModifiratlon �r00ter D !G GT-7p N <br /> Monitoring Well(s) 4 of Wells I Soil Borings) a"f ba""95 n Geotechnical notean^Irs <br /> -'OUl-Of-Service Well L Out-OfService Well Renewal Cross-Connection Repair <br /> New Pump -3 Pumo Re lacemerd a Pump Repair <br /> ❑Raise Well Cesln <br /> 1YELL CONSTRUCTION�� <br /> Drilling Method _✓btud Rotary C Afr Rotary G Auger C Cable Tool :1 Push Point n Other <br /> Proposed Wolf Depth Z(Q!R ExCavation 1Z in diameter E Open Bottom C Gravel Pack/Gravel Size <br /> 7 Conductor Casing In diameter / Conductor Casing Depth R in diameter <br /> Weil Casing Diameter_In Thldmess/Geuge/ASTM Sched C Steel , Plastic 7 Staln-ss Stet ^Other <br /> Grout Seal Depth ICO R D Neat Cement(94 Ib bag/5-10 gal water) <br /> end Cement !'t•�.3_seck mi f7 gel wafer <br /> �Bentonite(20%solids) n Other <br /> Grout Placement Metfiod I>(Pumped Free Fell -Other -1 Retardant/Accelerator(name) <br /> iPEp SE TAL Installed By O Driller �Pump Contractor 7 Other <br /> j -Concrete Pedestal ODlmenelons•Width R Length R Thick In Christy Box C Stove Pipe <br /> !PUMP Submersibfen Turbine e 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 /> 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 1 AM W COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> M MLLM 48 HO <br /> K}R J/jjJ1,V NCE NOTICE REQUIRED FOR INSPECTIONS PLEASE CALL(209)9553-7697 <br /> SIGNED (�� v V/ TITLE �p� nd^is 7►tAA/B `p 17 ZaZI <br /> r <br /> cYMFN <br /> Q 23 �0?1 <br /> /N C <br /> Fpq R�FN T y <br /> T <br /> DEPARTMENT USE ONLY <br /> Application Accepted By �,3 / Area <br /> S/f S'tl[k�Jil Employee IDN <br /> Grout Inspection By i Jw. ate_ '1] S—PECIAL Well Permit <br /> Pump Inspection By Date _- C WAIVER Received <br /> Sal Boring Inspection By Date Constructed Well Depth ft <br /> CONUAENTS - <br /> see ve arlt --_-_— <br /> Codes Info Cwh Remitted T1s Service R u s Invoice 0 Well ID! <br /> 1 <br /> EHD 43-05 61112019 <br /> • J�� 11 C/3�q WELL/PUMP PERMIT <br />