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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 <br /> WWW.S4 Ov.01' /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> CITY/ZIP ym <br /> CROSS STREET U APN r �j S <br /> PARCEL SIZE / -/ D <br /> LAND USE APPLICATION# � <br /> OWNER NAME O o <br /> 3 PHONE Q! -S vim, w <br /> OWNER ADDRESS O� �/ ��r� <br /> t CITYISTATE • n/ZIP I / <br /> (CONTRACTOR Or L(ZC. PHONE,;?10 _'9.?/—..ajy <br /> CONTRACTOR ADDRESS I a- ,( , 1 G A w <br /> CITY/$TATEIZIP <br /> SUBCONTRACTOR/CONSULTANT <br /> PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS <br /> CITYlSTATE/Z1P <br /> LICENSE j9,C-57 _ C-61 D-09 Othery� �'/(o <br /> NUMBER EXPIRATION DATE <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT �- <br /> DOMESTIC WELL SAMPLING:_.General Mineral/Coliform Bacteria(4391)_Dibromochloropropane(4392) _Arsenic(4393) <br /> INTENDED USE Domestic/Private _Irrigation/Agricultural -Industrial r_Water Quality MonilOring Soil SamptinglCharacterization <br /> Public Water System <br /> If different from Owner: Water System Name <br /> Contact Name o,Ph..Number <br /> TYPE OF WORK - New Well Replacement Well Well Alteration/Modification <br /> Other <br /> Monitoring Well(s) #of wells Soil BOM s a of borings <br /> Out-Of-Service Well 9O Geolechnical 7 of borings <br /> Out-Of-Service Well Renewal Cross-COnneCtiOn Repair <br /> -New Pum (Jum Re Out-Of-Service <br /> Pum Repair <br /> _Raise Well Casin <br /> WELL CONSTRUCTION <br /> Drllling Method Mud Rotary .. Air Rotary _Auger Cable Tool _ Push Paint <br /> Proposed Well Depth - Other <br /> P ft Excavation in diameter Open Bollom Gravel Pack/Gravel Size <br /> Conductor Casingin diameter <br /> in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched <br /> Steel _Plastic Stainless Steel Other <br /> Grout Seal Depth ft -Neat Cement(94/b bag/5-10 gal water) Sand Cement <br /> I Bentonite(20%solids) -:Other sack mixt)gal water <br /> 11 Grout Placement Method - Pumped .-Free Fall Other <br /> _ Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller _Pump Contractor - Other <br /> Concrete Pedestal Dimensions'Width ft Length R Thick m Christy Box Stove Pipe <br /> E�Np Submersible_Turbine -Other HP I L <br /> Pump Set it Standing Water Level It <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 COMP SATION L WS <br /> ' P. CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)95n= g? <br /> SIGNED TITLE ]//'//L�2 7 7 <br /> DATE �L 7 <br /> D <br /> VEL <br /> 2021 <br /> COUNTY <br /> ,ENTAL <br /> _ orx�+c�lT <br /> Ld <br /> �? I DEPARTMENT USE ONLY / <br /> Application Accepted By _ Date 7 P -`/ �! <br /> L)17 Area_ Employee ID# L) i`1 <br /> I <br /> Grout Inspection By — Date .. SPECIAL Well Permit <br /> Pump Inspection By Date �//b/,C.�/� _: WAIVER Received <br /> Soil Boring Inspection By Date <br /> COMMENTS Constructed Well Depth ft <br /> PE SC Received Check#/ Amount Permitl <br /> Codes Info B Cash Remitted Date S i Re s # Invoice# Well IDR <br /> 3KIi DLJ <br /> EMO.7-?6 6/ir2019 <br /> WELL tPUMP PERMIT <br />