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1 t <br /> WELL/PUMP PERMIT <br /> 4 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE <br /> ¢PERMIT y' www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS O O d`1 Cr CITY21P Oh �✓ zo? m <br /> r, C � D <br /> CROSS STREET Y\,I SOL l a v APN I q0 W DJc PARCEL SIZEV-j.At LAND USE APPLICATION# A <br /> m <br /> OWNER NAME PHONE ti <br /> OWNER ADDRESS �/ y7 CrTY/STATE21P <br /> CONTRACTOR k l e i n F21 ('• I'r/`C•/ C �J PP.ONE (�� ,Jn I <br /> CONTRACTOR ADDRESS ZOO I I I 0 l J&e l v CCrry/STATE/ZIP J�G I V�/' �!/ 9J "� <br /> SUBCONTRACTOR/CONSULTANT t/ ^ L AM Mac <br /> 1 V� PHONE <br /> I / —7-700 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS �J LZ� tI rs I CITY/]ST�ATEIZIP I ` �'yr,� ✓ `� <br /> LICENSE J C-57 - C-61 D-09 - Other NUMBER w O EXPIRATION DATE I 36 ?0 Z <br /> BILLING PARTY: S OWNER 4CONTRACTOR - SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:-General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring 4 Soil Sampling/Characterization <br /> Public Water System <br /> If different from O­r: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well 1 Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells r Soil Boring(s) 4 or borings J Geotechnical_ 3 of borings <br /> Out-Of-Service Well i Out-Of-Service Well Renewal 1 1 Cross-Connection Repair <br /> New Pum - Pump Replacement i7 Pump Repair L Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method.E Mud Rotary i Air Rotary 4 Auger 1 Cable Tool - Push Point J Other <br /> Proposed Well Depth 'W-60 It Excavation in diameter C Open Bottom I Gravel Pack/Gravel Size in diameter <br /> i Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched I_ Steel Plastic ]Stainless Steel I Other <br /> Grout Seal Depth 2o-60 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 V Pumped -Free Fall 1 Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller i- Pump Contractor - Other <br /> Concrete Pedestal_Dimensions:Width It Length ft Thick in Christy Box Stove Pipe <br /> Pu MP Submersible,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. 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 COMPENSATION LAWS. <br /> MINIMUM 48 H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-1 PLEASE CALL <br /> ALL(209)99531-76977 <br /> SIGNED `-"TITLE yDATE F._ <br /> C`c/V�r <br /> -ION ,B <br /> co,20 <br /> y4 <br /> 4 �Y <br /> DE AR MEN U NLY �� <br /> Application Accepted By Dat T Area �� Employee ID# — <br /> Grout Inspection B Date PECIAL Well Permit <br /> Pump Inspection By �//�� Date WAIVER Received <br /> Soil Boring Inspection By W17 Date 7/' Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By, Ca h Remittd -ice R e t <br /> EHD43-06 6/11/2019 /27/0 <br /> / WELL/PUMP PERMIT <br />