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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 />NUN-KEFUNDA/BIL t�.;y WyW�W.SSjgov.org/ehd ' w EXPIRES 1 YEAR FROM DATE ISSUE[ <br />JOB ADDRESS I O �)J �r'1`I%� ,[Jri�.AC�L 1 �r\U1 CITY/ZIP /-0'j) I <br />TJRN1=.2 _ P E <br />CROSS STREET ''j� L� /APlN� �J - i It _ ��' PARCEL SIZE )LAND USE APPLICATION # <br />OWNER NAME �r GA��J /Er/� �S 774 'L PHONE <br />PH�O�N�E�y_I�I <br />OWNERADDRESS 61 t3 C1tC- /CJ" 406 / CnY/STATE/ZIP0�G- O — <br />CONTRACTOR aE�ilnr�f't W67/4--4- IPL)mP PMr1NF��L)—G ,��iCYJ <br />CONTRACTOR ADDRESS <br />SUBCONTRACTORICONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE H/C-57 C-61 I D-09 <br />BILLING PARTY: ❑ OWNER <br />CITY/STATE/ZIP <br />PHONE <br />CRY/STATE/ZIP <br />Other_ NUMBER G '�, EXPIRATION DATE <br />CONTRACTOR 1 SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: o General Mineral/Coliform Bacteria (4391) F', Dibromochloropropane (4392) n Arsenic (4393) <br />INTENDED USE -i Domestic/Privaterrigahon/Agricultural C Industrial CI Water Quality Monitoring 7 Soil Sampling/Characterization <br />J Public Water System_ <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK VN.w Well i i Replacement Well i Well Alteration/Modification i i Other <br />-1 Monitoring Well(s) # of wells I Soil Boring(s) # or borings n Geotechnical # of borings <br />0 t -Of -Service Well Out -Of -Service Well Renewal a Cross -Connection Repair <br />P! New Pumo I PumD Replacement ❑ Pumo Repair ❑ Raise Well Casino <br />Drilling Method -1 Mud Rotary I i Air Rotary I Auger ❑ Cable Tool -1 Push Point ❑ Other f vCJ r IN K t. <br />Proposed Well Depth jC�o ft Excavation :�_q_ in diameter C Open Bottom C Gravel Pack/Gravel Size&Lb$ diameter <br />7 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter � In Thickness/Gauge/ASTM Schad l?"Steel C Plastic 7 Stainless Steel I 1 Other <br />Grout Seal Depth 90 If Neat Cement (94 lb bag/5-10 gal water) G/and Cement ZQ356C k- sack miX/7 gal water <br />-1 Bentonite (�0% solids) Other <br />Grout Placement Method PUmved i Free Fall i Other -1 Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller Pump Contractor I Other <br />:1 Concrete Pedestal LDlmensions: Width ft Length It Thick in I Christy Box Stove Pipe <br />PUMP -1 Submersible Turbine Other HP - Pump Set 3,0 ft Standing Water Level ft <br />1 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�F�— <br />S. <br />MDV OTICE REQUIRE^ COR INSPECTIONS -PLEASECAI 209) 953-76697 <br />SIGNED Ili��� DATE - r-/ <br />tYMENT <br />CEIVE® <br />3 0 2021 <br />QUIN COUNTY <br />ONMENTAL <br />DE ARTMENT USE ONLY <br />Application Accepted By" Date I Area �� Employee ID# <br />Grout Inspection B** Date ,Z ❑ SPECIAL Well Permit <br />Pump Inspection By Date r� WAIVER Received <br />Soil Boring Inspection By w -Date Constructed Well Depth ft <br />COMMENTS �i. /n�NO Z <br />PE SC Received Check#/ Amount Date Permit/ Invoice # Well ID# <br />Code Info B C sh Remitted Service Raguest # <br />312y0ijef)N:Z3cjq <br />C, <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />