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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PER1MIT? �� /� CALL(209)953-7697 FOR INSPECTIONS Err��XPIRES1 YEAR <br />�FROM <br />/y�DATE <br />/ISSUED <br />Joe ADDRESS I� { � J t"a✓7 /1�1P+. ZA CITY/ZIP -ij22A 1 CA 15..3(0(0 <br />CROSSSTREET Caf(D i+Vn APNo745-3 KoP PARCEL SIZE LAND USE�APrPPUCATON 9 Gr [� <br />OWNER NAME }�be 1p morf t t PHONE Zo`i • SDS • / I'L r <br />OWNER ADDRESS r D Box 5.31 CITYISTATE/7111 Y�'7 r CA y 5,jj0jj7n <br />CONTRACTOR Q fOlnl ``J /�PHONE ZO 1Q ( I L02 / (� <br />CONTRACTOR ADDRESS S J �C. CITYISTATE21P M(LY017 _ e- I_ A p J` 3131,2 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br />LICENSE :I C-57 ' C-61 !: D-09 I I Other NUMBER l D'�.27 1 fa FxPIRATION DATE 3 I I Za Z <br />DOMESTIC WELL SAMPLING:: I General Mineral/Coliform Bacteria (4391),l Dibromochloropropane (4392) r Arsenic (4393) <br />INTENDED USE Domestic/Private O •Irrigation/Agricultural Industrial Water Quality Monitoring i Soil Sampling/Characterization <br />i Public Water System <br />If ddl.—1 from Owner: Water System N.— Conlnrt Na— nl Pllona fJun iUer <br />TYPE OF WORK New Well I I Replacement Well i : Well Alleration/Modification I I Other <br />i Monitoring Well(s) # of wells i Soil Bonng(s) n of borinn 1 Geotechnical tt u1 banm s <br />I1 Out -Of -Service Well i: Out -Of -Service Well Renewal I Cross-Canneclion Repair <br />Drilling Method a Mud Rotary I Air Rotary ; Auger I I Cable Tool rI Push Point i! Other <br />Proposed Well Depth if Excavation in diameter I I Open Bottom Gravel Pack/Gravel Size in diameter <br />L! Conductor Casing in diameter / Conductor Casing Depth it <br />Well Casing Ciameler _ in Thickness/Gauge/ASTM Schad - Steel ! Plastic I Stainless Steel i- Other <br />Grout Seal Depth It I I Neat Cement (94 lb bag/5-10 gal water) ! I Sand Cement sack m&7 gal water <br />r1 Bentonite (20% solids) : i Other <br />Grout Placement Method L. Pumped LI Free Fall i Other 1 Retardant / Accelerator (name) <br />PEDESTAL Installed By D Driller I l Pump Contractor X Other <br />! Concrete Pedestal i0imenslons: Width ft Length ft Thick in i I Christy Box I: Stove Pipe <br />PUMP XSubmersiblel I Turbine i I Other HP Pump Se( fl Blanding Water Level fl <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. 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 COMP SA WS. <br />MINIly11 M Hg R /�AN�CE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 95/3-7697 <br />SIGNED / TITLE I'/ F''�7^ DATE <br />DEPARTMENT USE ONLY <br />Application Accepted By U /"�L� Date t AW -2/ Area q i�G • r Employee ID# FfZ <br />Grout Inspection By Date l..l SPECIAL Well Permit <br />Pump Inspection By Dale ��5 I �� I I WAIVER Received <br />Soil Boring Inspection By Dale Constructed Well Depth ft <br />COMME. . <br />to <br />D <br />R� YMFNr <br />CEJVA�D <br />JAN , 2021 <br />04 Qu CO <br />NO N vEP,4 TM4 NT <br />PE <br />Codes <br />SC Received <br />Info <br />Check#/ <br />Cash <br />Amount Date <br />Remitted <br />Permit/ Invoice # Well ID# <br />Se ce R&quest# <br />3g6 <br />6S! <br />.� <br />ISoZ • it <br />„����.f,'; I' ,ru�, <br />EHa i3-0 rev—<114f1E r �VELL/PUMP PERMrt <br />