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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1666 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 460-3420 <br />NDN -REFUNDABLE PERMIT — VJIIVW,51goV.orp;ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />Joa ADDRESS Q�7() Ci(/ .aa%j!1/i�f(�{.(/( 1/�i�{ ClTrfzla'I I LI/yw�/ <br />CROSSSTREAPN ! ���! UJ�J' l <br />PARCEL SIZE 1 �), LAND USE <br />❑INNER NA!dE PHONE -ZI <br />�/ � <br />OWNER ADDRESS CITY/STATcrZ'4 / ""ate� <br />CONTRACTOR PHONE((�/rcy�/ V <br />CONTRACTORADDRE SS CI7Y15TA7EfZl /�(-�)�1L `I q�515: <br />SUBCO!JTRACTORICONSULTANT PHONE <br />SUBCONTRACT ICONSULTAN7ADOf3ES5 CICI IST <br />LICENSE j -57 O C-61 O D-09 C Other NUMBER EXPIRATION DATE <br />BILLINu PlrRTY. ] OWNER J CONTRACTOR ❑ SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) D Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE D Dorneslic/PrivalerrigatiDNAgricultural 0 Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br />D Public Water System <br />1: different from Oancr. Wafer System Namc Conrad Name o: Ph— Number <br />TYPE OF WORK New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />❑ Monitoring Well(s) tr of wells ❑ Soil Boring(s) 4 cl borings O Geotechnical ',or borings <br />`u'uui-ur-aervlce vven O Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />y/�lew Pump ❑ Pump. Replacement ❑ Pump Repair 0 Raise Well Casing <br />WELL CONSTRUCTI N <br />Drilling Metho d�,Vtviud RM— -11 Air Rotary ❑ Auger ❑ Cable Tool D Push Point ❑ Other <br />Proposed Well Depth i t �- n Excavation in diameter ❑ Open Bottom ravel Pack/Gravel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth <br />Jk <br />Well Casing Diameter L.! in Thickness/GaugeIASTIA Schad �) ❑ Steel ''c IastiC 0 Stainless Steel ❑ Other <br />Grout Seal Depth -Z<;V _fl 0 Neat Cement (94 Ib bag/5.10 gar haler) 0 Sand Cement sack mixt gal water <br />Bentonite (20% solitls} <br />Grout Placement Method xPumped 0 Free Fall ❑ Other D Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller 0 Pump Contrador ❑ Other <br />9 Concrete Pedestal ❑Dimensions: Width it Lenqth n Thick in n Christ, Box n Scow Pine <br />(Pur,IP N� SubmersibleD Turbine 0 Other HP � Pump Set � k Standing Water Level L Sty f <br />I HEREBY CERTIFY THAT I HAV, PR,PGRFn THIO APP[ 11-ATIMI Ahln TunT Tu❑ ,mno,. , <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS, I ALSO CERTIFY THAT MY REQUIRED LICENSE 15 <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPS ATION LAWS. <br />MINNi, .vi 2 I.1OUf :�.DVANCE NOTICE REQUIRE=D FOP IINNSP CZIIIONS -j PLEASE CALL (209) 953-7/697 <br />SIGNED ��� TITLE J">+�l�r^�'A" DATE 7- <br />D EPARTMENT USE ONLY <br />Application Accepted BS, `�!` J% Date S ,? <br />Grout Inspection By Date <br />Pump Inspection By Dale <br />Soil Boring }nspeclion By Dale <br />COMMENTS �.OJ �JL:C.n io r•;o, (�;(� /� i�, t r�P1 1'sll)x /�P� <br />1 (1'!a.<'. ler" <br />N <br />PAYMENT <br />RECEIVE® <br />MAP 0 2 2021 <br />I I I I SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />Area l i Employee IDm V <br />T� <br />❑ SPECIAL Well Permit <br />0 WAIVER Received v U L <br />Constructod Woll Depth ft JI I <br />UFvJ�1(/?; l� <br />i <br />PE SC Received Checlulf <br />Codes Info ,/ - as <br />Amount <br />Remitted Date <br />PermW <br />Service Request 11 Invoice 11 I Well IDK <br />cl3�1 <br />Llai L <br />I I <br />