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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 />1� <br />NON -REFUND AB�/LE�PERMIT <br />— �/�/l I, lij t nrw.s' olg vor9lehd EXPIRES YEAR R M DATE ISSUED <br />tort u4 <br />JOB ADDRESS `-+J ► v ` jr t� / r CI f7J <br />CROSS STREET I APN-aygiaoya PARCEL $fZE 1D LAND USE IA/-P�'PLIC}1TION# Oa <br />OWNER NAME � 1 ��/� j c/[�. \ HONF 1 ' <br />OWNER ADDRESS)(w' 9�r 1' " ✓ `�' <br />CONTRACTOR -ET U d VV/ / P J • r v �� PHONE 0 <br />—r4 11.14 <br />CONTRACTOR ADDRESS -L I }/{T CITY S AYe/ /�t� 'r/1' <br />SUBCONTRACTOR/CONSULTAN Y 1A PHONE Jr V' l q <br />SUBCONTRACTOR/CONSUN/ <br />LT ADDRESS CITYISTATEI7JP h ,n <br />LICENSE C-57 C-61 D-09 , /ether NUMBER' EXPIRATION <br />BILLING PARTY: OWNER V CONTRACTOR SUBCONTRACTORICONSULTANT <br />ppYME <br />RECEI <br />SUN 2y DEPARTMENT USE ONLY <br />COUNTY <br />r$NAEA�.�rFi DE)tied By Date ('IR 1 <br />ENRCMPARTM6ZtInpoonBy Datea' <br />- <br />Pump Inspection By I ate <br />Soil Boing Inspection By Date <br />COMMENTS <br />)OMESTIC WEL`S,wPUNG: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDEO USE ^DomesticlPrivate Irrigation/Agricultural Industral Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />T iPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of oorings Geotechnical # of borings <br />Out -Of -Service Well` cJ�ut-Of-Service Well Renewal Cross -Connection Repair <br />New PumD PumD ReDlacement . XPumD Reoair . rRaise Well Casino _ r _ _ i <br />Drilling <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point 011ier <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 -Ihickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth_ ft Neal Cement (94 Ib bag/5-10 gal water) Sand Cement sack miXl7 gal water <br />Bentonite (20% solids) Other — <br />Grout Placement Method Pumped Free Fali Other Retardant / Accelerator (name) <br />I PEDESTAL Installed By unser Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Len th It Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other _ HPump Set ft Standing Water Level ft <br />,HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN y, <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS n <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL v , <br />WORKERS COMPENSATION LAWS. I, N <br />Area 4 l -- EmployeelD# <br />SPECIAL. Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received Che Amount ate <br />Codes InfoCall. Remitted <br />PetTnitl Invoice # Well IDS <br />Sery c # <br />392 050 — <br />EHD43.06 61112019 WELL 1PUMP PERMIT <br />