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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)46"20 <br /> NON-REFUNDABLE PERMIT www.sluov.org/ehd EXPIRES 1 YEAR FROM DATE IISSUED <br /> La <br /> Joe ADDREss , S. 0. C.MP 1 MSankt CO1 ""155,251 bey <br /> CROSS STREET G`y. , N2,&-1010 � PARCEL SME��LAND USE APPUCCATKI N a <br /> OWNER NAME 1(1�1 l�JU"Lr V C� Q�r- J. `^ PHONE • (�1 Ye <br /> OWNER ADORE j.' ,n.hL( ��I CRY/STATEIZW <br /> CONTRACTOR oI 1 pro , ` PHON,E1{ C <br /> J <br /> CONTRACTOR ADDRESS )i 01iSKU CRY/STATEIZ (�� <br /> W 1 1 I OV f- -rQ ,cp- 9 55 <br /> SUBCONTRACTOWCONSULTANT PHONE <br /> SUBCONTRAACTOOR)CONSULTANT ADDRESS CRYfSTATFJZIP �} <br /> LICENSE )6_57 i C-61 D-09 .Other NUMBER 2:)0'B I EXPIRATION DATE <br /> BIWNO PARTY; _:OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DoMEsnc WELL SAMPuNG: General ineral/Colifonn Bacteria(4391) Dibromochioropropane(4392)::Arsenic(4393) <br /> INTENDED Use Do(nestic/Prtvate IrTlgetiWAgriWtural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> I/dmtrent hom Owner. Water System Nemo Conley Name or Phe*Number <br /> TYPE OF WORK ANew Well 1 Replacement Well Well Alteration/Modification Other <br /> Monitoring Wallis) #of wells Soil Boring(s) 0 f tonna' Geotachnical s or bonn9s <br /> Out-0f-Service Well Out-01-Service Well Renewal Cross-Connecbon Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> Drilling MethodMud Rotary Air Rotary Auger Cable Tool 1 Push Point ; Other <br /> Proposed Well Depth 2.00 ft Excavation Z in diameter ]f Open Bottom Gravel PadJGravel Size 144).6 in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth )(Gravel <br /> ft <br /> asi <br /> Well Cng Diameter in Thickness/Gauge/ASTM Schad Steel Six :-Stainless Steel -Other <br /> Grout Seal Depth '-"50 it Neal Cement(9416 beg/5-10 gal wafer) nd Cement to 3 sack mixll gal water <br /> Bentonite 20%solids) Other <br /> Grout Placement Method Pumped .Free Fall , Other Retardant I Accelerator(name) <br /> PEDESTAL Installed By Drider mp ConUactor Other <br /> is Concrete Pedestal DI enslons:Width ft Length it Thick in '.-Christy Box Stove Pipe <br /> PUMP ":Submersibles'?Turbine Other HP Pump Set It Standing Water Level ft <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. 1 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 /> INIMUM 48 HOUR ADVANCE NOTICE REQUIRED INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Y , ! DATE <br /> 7 ; , <br /> R P�� <br /> T <br /> lDEPARTMENT USE ONLY 1 //�J/� <br /> Application Accepted By �Z L— Data -� 1 Area L T' c Employee ID#� 1 <br /> Grout Inspection By L <br /> Date L r L` , - SPECIAL Well Permit <br /> Pump Inspection By Date - WAIVER Received <br /> Soil Boring In By Date Constructed Well Depth R <br /> CON"ENTS , �,rp i j� i Gv< J <br /> >✓� Il ( s ice <br /> PE SC Recetmd Amount D Permit/ Invoice# Well ID* <br /> Codes Info B Remitted Arrvist Filiquest 0 vJ I <br /> L, I gC) <br /> EHD43O6 01112019 WELL/PUMP PERMIT <br />