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P <br />4 <br />"►a WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468.3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRE 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS CITy/ZIP • F A 4'P td6- <br />1'L J �J <br />CROSS STREET APN /' 0 { O O %- PARCEL SIZE I • - LAND USE APPLICATION # <br />OWNER NAME <br />S G•`/,�/. X // —jr;� ( LP'H..O; NrLE h/ <br />PHONE <br />ADDP <br />' <br />CONTRACTOR �'r I !��" = S- 1 _t .�/Y� 1 L' stir' �' PHO/NE <br />CONTRACTOR ADDRESS J L �' �' '�1['..y�, �- CITYISTATEIZJP y I'f• (�• �LL / S <br />SUBCONTRACTOR PHONE <br />/-T <br />SUBCONTRACTOR ADDRESS CITY/STATE/7JP <br />LICENSE 7 C-57 VC -61 G D-09 r Othef NUMBER I L, ,, EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: '7 General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural D Industrial D Water Quality Monitoring - Soil Sampling/Characterization <br />I <br />ublic Water System <br />if different from Owner Water System Nam. Contact Name or Phone Number <br />TYPE OF WORK O New Well p Replacement Well 7 Well Alteration/Modification :' Other <br />D Monitoring Wells) 4 of welts 71 Soil Boring(s) a of boringsL., Geotechnical s of borings <br />fl Out -Of -Service Well -1 Out -Of -Service Well Renewal Cross -Connection Repair <br />U New Pump C Pump Replacement 0 Pump Repair Raise Well Casino <br />Drilling Method n Mud Rotary Air Rotary - Auger I"I Cable Tool Push Point F Other <br />Proposed Well Depth ft Excavation in diameter -_ Open Bottom C Gravel Pack/Gravel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched 0 Steel U Plastic C Stainless Steel D Other <br />Grout Seal Depth ft L Neat Cement (94 Ib bag/5-10 gal water) i Sand Cement sack mixr7 gal water <br />'L Bentonite (20% solids) I_ Other <br />Grout Placement Method -- Pumped _ Free Fall '-: Other G Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller a Pump Contractor LJ Other <br />❑ Concrete Pedestal -iDimenslons: Width ft Length ft Thick in -1 Christy Box C Stove Pipe <br />PUMP Submersibles Turbine rl Other HP Pump Set ,LN ft Standing Water Level ' C 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 COMPE AT S. <br />dl'sl�i [s ,r^^�ANCE NOTICE REQUIRED FdNSPE=.(,TIOF c: - PLEASE CALL (209) 953 697 <br />SIGNED TITLE P4I 1+ 1 �,' r 1 <br />111 DATE4 / <br />g <br />IN <br />f !f <br />YMENT <br />CEIVED <br />13 2021 <br />JOAQUIN COUNTY <br />TH DEPARTMENT <br />M E N T USE ONLY <br />Application Accepted By � l Date �) 1-'5 l <br />7 <br />Arear�r I Employee ID# <br />Grout Inspection By <br />Pump Inspection By <br />Date <br />Date - 1 <br />❑ SPECIAL Well Permit <br />1� WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Dale _ <br />Constructed Well Depth <br />K <br />C:. I hip X?&fiA! � <br />EH0 43-06 revised 4/14/18 WELL !PUMP PERMIT <br />