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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1669 EAST HAZE LTON AVENUE-STOCKTON CA 95205-6232(209)460-3420 <br /> NON-REFUNDABLE PERMIT S WWW. Ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS M 1 ' 61vv'VCITY/zIP Li 0 N <br /> D <br /> 0 <br /> CROSS STREET APN2�Kj(d Ol ARC EL SIZE LAND USE APPLICATION# s <br /> OWNER NAME t L PHON v 3 2 [\ <br /> OWNER ADDRESS` 1✓,,l / h CITYISTATE/ZIP 12 <br /> V-61' GL�J'L/�J/•� <br /> Y V I t� I I I I� PHONE r�O�• V/ CX <br /> CONTRACTOR (1 /µr,[,y`1 g y�{,a �jt� L� <br /> CONTRACTOR ADDRESS `-' 4�L-N` I ' r l{� CITYISTATFJZIP�IV�/• n�) ✓• �t� (� <br /> SUBCONTRACTORICONSULTANT I' \� PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATE21P <br /> LICENSE y C-$7 C-61 D-09 Other NUMBER EXPIRATION DATE <br /> BILLING PARITY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)' Arsenic(4393) <br /> INTENDED USE y <br /> DomesticiPrivate Irrigation/Agricultural Industrial Water Quality Monitonng I Soil Sampling/Characterization <br /> Public Water System <br /> If d,ee,ent from Owner Wale,Syvem Name Conlad Name or Phone Number <br /> TYPE OF WORK 7C New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Weil(s) #of wells Soil Bonng(s) a of borings Geotechnical a of bonnp <br /> C'Out-0f-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method?(Mud Rotary Air Rotary i Auger Cable Tool I Push Point f I Other <br /> Proposed Well Depth 0-D h Excavation (2— in diameter 7 Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conduc r Casing in diameter / CondCuctcr Casing Depth ft <br /> We Casing Diameter In Thickness/Gauge/ASTM SchedJ 7 I steel Plastic Stainless Steel -Other <br /> Grout Seal Depth u./ It Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> ?._Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other I Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions Width it Length It Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set IT Standing Water Level tt <br /> 1 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 /> WORKERSP S T10N LAWS. <br /> MI IM 4 O R VA NOTICE REQUIRED F( IIJ,IN�S TTIIO�.N/SS-PLEASE CALL(209)9 3-7 97 <br /> ED <br /> SIGNTITLE Y V� � v, DATE I `i <br /> IVNT <br /> E® <br /> 2020 <br /> NTUNi <br /> AL <br /> TMENT <br /> DE NT U E� 2O LY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection Byr <br /> Date PECIAL WBII Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth �u'O ft <br /> COMMENTS <br /> PE SC Received Check Amount Dale Permit/ Invoice# Well ID# <br /> Codes Info Remitted Service Re uest# <br /> ZO <br /> 41 <br /> EHD43-06 &'11/2019 WELLIPUMPPERMIT <br />