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MORMIltyd»:illIN <br />SAN.)OAQUIN COUNTY ENVIRONMEN <br />AL <br />DEPARTMENT <br />1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />MIT <br />NON-REFUNDABLE PE-RR <br />C,� I <br />JALTH <br />VJ WW.s <br />ov.or /ehd <br />EXPIRES 1 YEAR FROM DATES ISSUED <br />JOB ADDRESS /� / <br />J <br />/ <br />(/(%/ SG <br />CITY/ZIP z/Z7�eA <br />/ ✓� <br />CROSS STREET D/-yPND,?D/ply? <br />-DMZ PARCEL SIZE.X'I 9 LAND USE APPLICATION # <br />Ll3:6id <br />/ C <br />OWNER NAME O✓S/�'�/�l�f'--'��✓ <br />57 ✓�/T'if-- <br />L7%%/'F� <br />PHONAAJ�j/j��z`{U <br />Ct <br />OWNER ADDRESS / �/� - <br />AiZ,l-- ��l <br />CITYISTATEIZIP <br />/��✓� <br />���"� '// 9?:5;i ( <br />CONTRACTOR Ajyi,.i�//f�S <br />fes(/ rl-�l7� <br />.Ori/ <br />93�1�-J 3z.{n <br />CONTRACTOR ADDRESS �21,,-/V1/%/J��%ILS <br />G�TJ/�.� /�-� <br />CITY/STATEIZIP <br />CPHONE <br />lo <br />SUBCONTRACTOR/CONSULTANT / �'//1 <br />54 � S %GLS <br />) <br />/l.G� <br />PHONE <br />SUBCONTRACTORICONSULTANT ADDRESS <br />LICENSE /VC -57 �-61 0 D-09 D Othef <br />/CIT/YISTATEIZIP <br />NUMBER `oOZ <br />EXPIRATION DATE 3y Z <br />BILLING PARTY: D OWNER <br />0 CONTRACTOR <br />0 SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING,,, General Mineral/Coliform Bacteria (4391)Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE pebomestic/Private ❑ Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br />❑ Public Water System <br />If differenl from Owner Water System Name Contact Name ar Phone Number <br />TYPE OF WORK 'VNew Well 0 Replacement Well 0 Well Alteration/Modiftcalton D Other <br />0 Monitoring Well(s) # of wells ❑ Soil Boring(s) A a borings ❑ Geotechnical a of bonngs <br />El Out -Of -Service Well ❑ Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />I/NeW Pump 0 Pump Replacement 0 Pump Repair ❑ Raise Well Casinq <br />Drilling MethodVlAud Rotary D Air Rotary 0 Auger 0 Cable Tool U Push Point ❑ Other <br />Proposed Well Depth295:0 ft Excavation /Z in diameter 0 Open Bottom gavel Pack/Gravel Size 4f <br />in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter _A�p in Thickness/Gauge/ASTM Sched 's -.7C ❑ Stee�laslic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth R Cl Neal Cement (94 lb bag/5-10 gal waler) D Sand Cement sack mix17 gal water <br />'IV Bentonite (20% solids) ❑ Other_ <br />Grout Placement Method Pumped 0 Free Fall 0 Other D Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller yYJPump Contractor/D Other _ <br />D men <br />Concrete Pedestal O sions: Width �_ ft Length / fl Thick in (-I Christy Box ❑ Stove Pipe <br />PUMP '4Submersible❑ Turbine ❑ Other HP �_ Pump Set_1(d) ft Standing Water Level ��4 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 COMPENSATION LAWS. " <br />MIt 48 HofJ/4DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />G <br />Application Accepted By ` L Date 3 / J % Area / Employe *# Af <br />Grout Inspection By Date ❑ SPECIAL Well Pef Y�E T <br />Pump Inspection By Dale ❑ WAIVER Received"FCP1j ­ <br />Soil Boring Inspection By <br />COMMENTS _ E n I S l i ll, <br />Date <br />Constructed Well Depth <br />PE <br />Codes <br />SC Received <br />Info B <br />Check Amount <br />��� <br />Cash Remitted <br />Permit <br />Date Invoice # OFpy �1�1 <br />. I Service Request # R <br />j_��o <br />C,� I <br />1r_;� <br />? U;'J <br />F <br />LI ZL,L, <br />J <br />�• ,�D <br />a ;r�� �. <br />y3�1 <br />fIS(_) <br />Ll3:6id <br />70 <br />tq) L <br />EH043-06 5112019 V WELL [PUMP PERMIT <br />�p� I�II�'v'lIK <br />N1! Gj <br />