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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DWELL/PUMP PERMIT <br /> r DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205.6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT WWW.S' py,Or /ehd EXPIRES 1 YEAR FRO DATE ISSUED <br /> Joe ADDRESS <br /> CITYZPnj N <br /> n <br /> m <br /> -1 , <br /> CROSS STREET �-C�• A ` r �ya'1 PARCEL SIZE D <br /> LAND USE APPLICATION# 0 <br /> OWNER NAME PHONE 070Q-S(p/- a3q A <br /> N <br /> OWNER ADDRESS D <br /> CONTRACTOR <br /> 11 ��'�� CITYI$TATE/LIP— <br /> �Q�YmahrS <br /> t, PHONE - D <br /> CONTRACTOR ADDRESS alga <br /> CITY/STATEZP <br /> $UBCONTRACTORICONSULTANT <br /> PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS <br /> CITY/$TATE/ZIp <br /> LICENSE ).0-57 C-61 D-09 <br /> 011ier NUMBER & EXPIRATION DATE <br /> BIL LING PARTY: OWNER Y,CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)=Dibromochloropropane(4392)_Arsenic(4393) <br /> INTENDED USE ,1L DomestirJPrivate _Irrigation/Agricultural -Industrial <br /> Water Quality Monitor ng Soil Sampling/Character zation <br /> Public Water System <br /> If dfferenl 6om Owner: Water System Name <br /> Contact Name or Phone Number <br /> TYPE OF WORK -New Well Replacement Well Well Alteration/Modification <br /> Other <br /> Monitoring Well(s) of wells Soil Boring(s) #of borings <br /> Out-Of-Service Well _Geotechnical #of borings <br /> Out-Of-Service Well Renewal Cross-Connedion Repair <br /> _New Pum Pum Re lacement Pum Repair <br /> WELL Co----sTRucTI°N =Raise Well Casin <br /> Drilling Method Mud Rotary Air Rotary _Auger Cable Tool Push Paint <br /> Proposed Well Depth Other <br /> P ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size <br /> Conductor Casing in diameter / Conductor Casing Depth ft in diameter <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched <br /> Grout Seal De th Steel _Plastic _Stainless Steel Other <br /> P ft Neat Cement(94/b bag/5-10 gal water) Sand Cement <br /> Bentonite(20%solids) __Other sack mixt]gal water <br /> Grout Placement Method - Pumped .-Free Fall - Other <br /> Retardant/Accelerator(name) <br /> PEDESTAL Installed By - Driller _pump Contractor -- Other <br /> - Concrete Pedestal_Dimensions:Width ft Length it Thick <br /> in -Christy Box :=Stove Pipe <br /> PURIP K Submersible_Turbine -Other Hp <br /> Pump Sel 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 /> fit (},UIVI } VANCOTICE REQUIRED F INSPECTIONS•PLEASE CALL(200)9 1--6 <br /> SIGNED ^ <br /> TITLE DATE a <br /> PAYMENT <br /> RECEIVED <br /> AUG 12 2021 <br /> JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> EALTH DEPARTMENT <br /> �.� DEPARTMENT USE qNLY <br /> APPlication Accepted By I �l���Li Date Zi Area iL /� <br /> /Q { <br /> Grout inspection By Date Employee ID# <br /> SPECIAL Well Permit <br /> Pump Inspection By Date 09 WAIVER Received <br /> Soil Boring Inspection By Date <br /> COMMENTS Constructed Well Depth ft <br /> PE SC Received Checkk! Amount <br /> Codes Info Date Permit/ <br /> Cash Remitted S est R Invoice Well ID# <br /> EHD 13} Eli no,0 <br /> WELL?UMP PERRIIT <br />