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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1858 EAST HAZELTON AVENUE-STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLFPERMIT n www-sinov-ora/ehd I A EXPIRES 1 YFAR FRnM ❑ATF ICRIIFr1 <br />JOBADDRES� r CuTt -kCITY%Z,P <br />LA <br />1L. <br />'] Q ]� <br />CROSS STREET V 1�ll 9 0 O O V _PARCEL SIZELAND U4 APPLICATION # <br />OWNER NAME ` LG. PHONE <br />Amount ate PenmU Invoice # Well ID# <br />Remitted Service Re uest # <br />��( _ <br />Cn3 TV <br />OWNER ADDRESS 11 e ( c, <br />_ �,�^ <br />3V <br />.../����' ,L'� <br />,,�r^�, 1 <br />CONTRACTOR V ` A4 VS t(( _ " ' ' Jn c •1V1 01\PPH/tv <br />4 7 7— <br />�jf G� <br />CONTRACTOR ADDRESS (A CITY/ ' .+ l 53 5 O <br />1j,OON/�E <br />__ T .7 <br />_ <br />1P <br />SUBCONTRACTOR/CONSULTANT - P240 NIc <br />SUSCONTRACTOR/CONSU <br />T ADDRESS ^��/CITY//STnATEI/L,,P/�N <br />LICENSE C-57 C-61 D-09 NUMBER�'�� "' �W v EXPIRATI A <br />' /Other <br />BILLING PARTY: OWNER I/ CONTRACTOR SUBCONTRACTORICONSULTANT <br />e" <br />DOMESTIC WEL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) c^ <br />INTENDED USE omestic/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 OF WORK New Well Replacement Well Well Alteration/Modification Other _ <br />Monitoring Well(s) # of wells Soil Boring(s) "e' borings Geotechnical K of oonngs <br />Out -Of -Service Well,ynut-Of-Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement XPUmp Repair1ise Well Casing' <br />WELL CONSTRUCTION pmp b <br />r: <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth_ 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/ASTM Schad Steel Plastic Stainless Steel Other <br />(^ <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mixf7 gal water <br />Bentonite (20% solids) Other <br />_ <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 Le gth ft Thick in Christy Box St ve Pipe <br />PUMP Submersible Turbine Other HP Pump Set_ _ ft 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WIT THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS NSATION L <br />MI I M 48 HO AD NOTICE REQUIRED F INSP�E/C�TIIO�NyS� - PLE�A/AE CALL (209}9 '�" "7 <br />SIGNED A TJ LE __. Yi_[ �_T_ y_I HILL_' DATE �p (p �(� <br />:� �■■■■■■■■■ R�■■■■■■■ ■��u=ii ■i �a■ice=i■■■ <br />11 UT. 1f■■■■■■■■ ■■■■ ■M■■■ -Mile N■O•i■■■ <br />. w .,th.: a By D• A 67 <br />PENVIRONMEN&O,ctio, By Date SPECIAL Well Permit <br />ALTH E)"AR' mp Inspection t ir AL Date'WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />• - <br />4- <br />i <br />�L <br />Q\� <br />EHD43-06 61112019 WELL/PUMP PERMIT <br />PE <br />Codes <br />SC Received hec <br />Info B a <br />Amount ate PenmU Invoice # Well ID# <br />Remitted Service Re uest # <br />3V <br />OSo <br />4 7 7— <br />_ <br />EHD43-06 61112019 WELL/PUMP PERMIT <br />