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{ <br />} <br />WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT <br />l , Z <br />ES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS G..JOfCITY/ZIP <br />11f -2 r <br />CROSS STREET eis"O ' Z _ A P N i� / / O / PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME �l— 9s�n ��///� j G�S /PHONE?�-7��� <br />OWNER ADDR*ESS c/�j • ,% / CITY/STATEIZIP C,;K4 <br />CONTRACTOR �Y—/• ", SX7yn �LL` PHONE <br />CONTRACTOR ADDRESS d� 17L-? CITY/STATE/ZIP <br />SUBCONTRACTOR/CONSULTANT l% " ~� PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br />LICENSE b -M< 57 ❑ C-61 U D-09 ❑ Other NUMBER 3-" 3�� EXPIRATION DATE <br />BILLING PARTY: OWNER I i CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) 1 Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private rrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System _ <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK >Kew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal D Cross -Connection Repair <br />yflew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casina <br />WELL CONSTRUCTION <br />Drilling Method,> -Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point E -I Other _ <br />Proposed Well Depth6'0 it Excavation in diameter 0 Open Bottom X13 ravel Pack/Gravel Size _ in diameter <br />❑ Conducaj Casing in diameter / Conductor Casing Depth it <br />Well Casing Diamete�r in Thickness/Gauge/ASTM Sched 2 --�- El Steel Plastic ❑ Stainless Steel ❑ Other,. <br />Grout Seal Depth ,J O ft ❑ Neat Cement (94 Ib bag15-10 gal water) Ll Sand Cement l3 sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other J` <br />Grout Placement Method dumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By >4briller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box Cl Stove Pipe <br />rPumP ubmersible❑ Turbine ❑ Other HP Pump Set it Standing Water Level it <br />I 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIM!Uy 48 HOU DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)) 953-766971 <br />SIGNED TITLE 1/"� DATE Il L ` <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring I <br />COMMENTS <br />Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />T <br />m <br />0 <br />0 <br />A <br />W <br />PE Sc <br />Codes 14fo <br />Received <br />C ec Amount Date Permit/ Invoice # Well ID# <br />ash Remitted Service Request # <br />� (2.2.1q WP 35D <br />2.2•I°l 00 CA 0 S <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />