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WELL/PUMP PERMIT <br />SAN JOAQUIN CrUNT ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468.3420 <br />NON-REF_UN A_13 E PERMIT www. jgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CITY/Z1 <br />/ <br />CROSS STREET %� / Y(/c A 4;N jd -3— <br />PARCEL SIZE ` 9P r /S LAND USE APPLICATIION # <br />OWNER NAME <br />/p <br />PH�ON/E�'_/O/7��/O�Z�yJS��`C/ <br />�Q 4,J �%�JIG <br />OWNER ADDRESS _ / <br />f—'Y(/ 7 459 —�//� 4;0q—/ Jp <br />/',�'//j��/V <br />CONTRACTOR G"'�"/vim y�/L�L�•'L <br />CONTRACTOR <br />TCITY/STATE/ZIP <br />PHONE <br />CONTRACTOR ADDRESS iLL G GD <br />CITYISTATEIZIP <br />��L <br />SUBCONTRACTORICONSULTANT ,/�L"'�� A�/"ILLJ <br />PHONE <br />SUBCONTRACTORICONSULTANT ADDRESS <br />CITYISTATFJZIP <br />LICENSE �-57 1�t-61 U D-09 U Other <br />NUMBER KeM&ltlpEXPIRATION DATE <br />BILLING PARTY: U OWNER U CONTRACTOR J SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: XGenerai Mineral/Coliform Bacteria (4391)xDibromochloropropane <br />(4392) (.1 Arsenic (4393) <br />INTENDED USE I . omesliclprivate- 'rrigation/Agdculturai G Industrial <br />-. Water Quality Monitoring CI Soil Sampling/Characte stip <br />•�C6��{%L�" <br />II Public Water System <br />If oilterenl from Owner Wale, System Name <br />Contact Name or Phone Number 1A A, - <br />TYPE OF WORK -VNew Well L Replacement Well L' Well Alteration/Modification U Other v ' -' K 7I19s <br />'ANU Monitoring Well(s) # of wells D Soil Borings) p of borings L Geotechnical Jp,(�j g" <br />'� Out Well Renewal I t Cross Repair Hz'LT <br />f_I Out -Of -Service Well I -Of -Service <br />-Connection QONMENTq� <br />AL <br />tNAew Pump D Pump Reolacement IA Pump Repair <br />I I Raise Well Casing £p�11 7, <br />WELL CONSTRUCTION <br />Drilling Method VM"dRotary �y� Air Rotary U Auger ❑ Cable Tool 1, Push Point U Other <br />Proposed Well Depth Zd !— It Excavationin diameter D Open Bottom ,VGravel Pack/Gravel Size in diameter <br />eter <br />I I Conductor Casing in diam/ Conductor Casing Depth N <br />Well Casing Diameter --F in Thickness/Gauge/ASTM Sched /—") ! i Steel Plastic l I Stainless Steel �� Other <br />Grout Seal Depth /Uri it !3 Neat Cement (941b bag/5-10 gal wafer) .1 Sand Cement sack mix17 gal water <br />Bentonite (20% solids) i I Other <br />Grout Placement MelhodAumped IJ Free Fall 0 Other L Retardant / Accelerator (name) <br />PEDESTAL Installed By U Driller 1 Pump Contractor I I Other <br />U Concrete Pedestal DDimensions: Width it Length It Thick in U Christy Box J Stove Pipe <br />PU61P—oubmerslbieD Turbine u Other HP Pump Set it Standing Water Level O —It <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 COMPENSATION LAWS. ' <br />MIN [MUMAWHOUR AWANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9,53-76 7 <br />Application Accepted By ` % Date "l.7V Ii;` Area `>' `i % Employee ID# 014• <br />Grout Inspection By Date E SPECIAL Well Permit <br />Pump Inspection By Date I I WAIVER Received <br />Soil Baring Inspection By Date Constructed Well Depth it <br />COMMENTS EzLQI41t vdel( to rPl �Jf Jcd to 64 or, I/, <br />PE SC Receivedsphcka <br />Codes Info B <br />CastI <br />Amount Permit] Date Invoice # Well ID19 <br />mitted Service Re uest # <br />L(zc h iso — <br />Lr�o y <br />(p <br />L13�I l - <br />-0 <br />:Iso rljl <br />L S/ <br />70 tl 1 <br />EHD43-06 6/11/2019 WELL ]PUMP PERMIT <br />I��� itl iUw�uY <br />