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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUND#W PERMIT. WWW.Sj90v.org/ehd EXPIRES'I YEAR FROM DATE ISSUED <br />JOB ADDRESS p VL 11 ''nn _ CITY/ZIP <br />V <br />V1 Lf 5u <br />CROSS STREET D i` m l LN l µ N(90'5C)'7-j'0 1 a✓ !J <br />r` / PARCEL SIZE LAND ULEy/APPLICATION #S <br />OWNER NAM d "L IfVCj PH NE 1 ' ✓ <br />OWNER ADDRE S' U CITY/ST ((v I, ,l <br />�5 326 <br />CONTRACTO73, -enPHONE <br />CONTRACTOR ADDRESS ��" H CIN/STA IP <br />SUBCONTRACTORICONSULTANT ONE 1V�� <br />SUBCONTRACTOR/CONSUL,7 ADDRESS CY�ITY/S�J� <br />TTATTEIIZY/)P <br />LICENSE C-57 C-61 D-09 he NUMBERJ6(90 EXPIRATIONDATE J 13 �Ir <br />BILLING PARTY: OWNER ONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WEL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE Domestic/Private Irrigation/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 C= WORK ".ew Vveii Replacement Vveil Well Aiteratlon/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) _ # of borings Geotechnical # of borings <br />Out-Of-Servi�Wjll Out -Of -Service Well Renewal Cross -Connection Repair <br />New PumD �SPumo Replacement PumD Repair Raise Well Casino <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter Open Bottorn Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth _ ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack m/x17 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />,Concrete Pedestal Dimensions: Width ft Lepgth It. Thick in Christy Box Stove Pipe <br />PUMP V Submersible Turbine Other HP -L_. Pump Set ISS ft Standing Water Level ' u ft <br />1 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 I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATIO WS. <br />MIW&M 48�AANCE NOTICE REQUIRED FO 1 ECTIONS - PL//E'��A��//gyyq������ CALL (209) 7 <br />SIGNED +1 TITLE Ina/ • DATE j <br />9 <br />m <br />N <br />`1 <br />n <br />s <br />Grout Inspection By _ bate fL_ SPECIAL Well Permit <br />Pump Inspection By Date U 1 1� 5�2� WAIVER Received <br />Soil Boring Inspeon By Date Constructed Well Depth _ It <br />COMMENTS W J.'111? OU 16 .411 <br />PE SC Received Che <br />Codes Info By ash j <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted S ryice Request # I <br />DSO <br />EHD43-06 6H112019 WELL/PUMP PERMIT <br />