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• WELL/PUMP PERMIT <br /> SAN JOAOUIPI COUNTY ENVIRONMENTAL HEALTH DEPARTMENT kind EAsr HAZELrOAI AVE%LE.S TOCKTON CA 35205•0232(209)16d-3120 <br /> NON-P-FUNDABLE PERMIT _ wiArm.s• o� v.org/ehd EXPIRES 1 YEAR FROM DA r=-ISSUED <br /> V1 11[k)OU OZ ;Jca ADCP._33 _ 1 <br /> > <br /> Dom• CI r2!P ) Li,d 1 Jlj1 <br /> 1 't pn <br /> �texory �CRoss S*REE" VA o`r y_APN_ y O _Paa,:EL Srl4't0t� LaNC USE AaP lr_a 1GN a" a <br /> 1 <br /> ICWhER NAME T <br /> !L� PHONE <br /> jOWNERAODRES3 _31i;� CITY/SrATE,ZIP Tirg <br /> CONTRACTOR U3 V1 1 ,11 PHONE -N((201'v1)n+ tbq�cJ-JT)y1f-+]10 <br /> CONTRACTOR ADDRESS CTISTATE!ZP G,-Lk <br /> i N <br /> Cor I <br /> SUBCONTRACTOWCONSULTANT y�,J(� Iµ,11( -+ {.{AC�'`�ySOI.�(Zt�I �rPOHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS �7V�O lYI��J tGtl I� , CITY/STATE/ZJP Lae4J ' VQ'�' u't 1 �� •' <br /> LICENSE ✓•57 C-61 =D-99 = Other NUMBER <br /> O R t•V EXPIRATION DATE 7/JG�qa L <br /> BILLING PARTY: OWNER _CONTRACTOR V SUBCONTRACTORiCONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)L Arsenic(4393) <br /> INTENDED USE DomesticPrivate -Irrigation/Agricultural '_Industrial Water Quality Monitoring oil Sampling/Characterization <br /> Public Water System <br /> If lifferent from Owner Water Systam Name Contact Name x phone Number <br /> TYPE OF WORK New Well C Replacement Well Well AlterationtModificafion =Other <br /> Monitoring Well(s) #of wells Vi61 S.ring,$)9— #'f henngs .Geotechnical #of bonngs <br /> Out-Of-Service Well Out-Of-Sarvica Y/ell Renewal Crass-Connection Repair <br /> New Pump Pump Replacement --Pump Repair =Raise Well Casing <br /> WELL CONSTRUCTION <br /> .Drilling Method .Mud Rotary =Air Rotary V"Auger Cable Tool _Push Point -- Other <br /> Proposed Well Depth 1_ft Excavation in diameter --Open Bottom Gravel Pack'Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness%Gauge/ASTNI ached - Steel =Plastic Stainless Steal .-. Other <br /> Grout Seal Depth 15 ft ±-beat Cement 194 lb Sag5-10 gal water) =Sand Cement sack miai7 gal'.vater <br /> Bentonite(20%solids) -- Other <br /> Grout Placement Method Pumped ' Free Fall e:they tf2711112 I =Wo�19BXnq xelerator tname) <br /> I <br /> PEDESTAL Installed By Driller C Pump Contractor C Other <br /> Concrete Pedestal=Dimensions:Width It Length ft Thick in Christy Box C Stove Pipe <br /> PUMP =Submersible=Turbine ❑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 /> MINV 48 HOUR^yeDVAN-CE NOTICE REQUIRED FOR INSSP TIONS-PLEASECALL(209)9553-769\7_ <br /> SIGNED / `- v TITLE I r t t'C"� DATE J�2J1 <br /> I <br /> I <br /> i I I i III EIVEp <br /> I I I I <br /> 6 2021 <br /> IN COUNTY <br /> RDUMENTAL <br /> AR.rh,SIT <br /> DEPARTMENT U E N L Y <br /> Application Accepted By `—Z' Date d aZ Areaf 1 G Employee fD# AR <br /> _ <br /> Grout Inspection By Date SPECI L Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Baring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date PermiU Invoice# Well ID# <br /> Codes Info s Remitted Service Re u <br /> �a o <br /> I <br /> E•+C t:-.d 5It"2p 13 NE:1 P''dF'aEp•.II* <br />