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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> !�� ` y <br /> JOB ADDRESS 0 \ < CITY/ZIP mGt. 0. <br /> `11 D <br /> CROSS STREETS ,_(�� -XliA �U r `N 2_�O�O r PARCEL SIZE LAND USE APPLICATION# p <br /> OWNER NAME MCY I k-11 t� KI�f V—', CO•V\ \(A.' yS�C• PHONE <br /> R(�( C� ��/ S /j c (�Q <br /> OWNER ADDRESSES V Y0 ..J"I �,Q� I W A.�'L�r MY J�C /'1 CITYIS7ATE21P ,,7 Q�,,u(� G.ph l7 v•` <br /> CONTRACTOR ' ie'AA yDirOS•OT ilk ���CrIY�ISTATEIZI�PrMIDJ'C,5—t-0, <br /> C. PHONE7J �U�Jyg015t0CONTRACTOR ADDRESS I �L.J � C/\ /�,�y J� <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATE/ZIP <br /> LICENSE X C-57 C-61 D-09 Other NUMBER L.�10 t/ L J EXPIRATION DATE 15 <br /> BILLING PARTY: OWNER ONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)C Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial i Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Weil Replacement Well ❑Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings Geotechnical a or borings <br /> Out-Of-Service Well ❑Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL C NST I <br /> Drilling Method Lid Rotary 0 Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well epthP)()o_ft Excavation ?_,.in diameter Open BottomGravel Pack/Gravel Size IT diameter <br /> i'Conductor Casing in diameter / Conductor <br /> nCasing Depth (("" ft <br /> Well Casing Diameter n Thickness/Gauge/ASTM Sched 5D 121 SteelPlastic i7 Stainless Steel Other <br /> Grout Seal Depth _ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement C). sack mix/7 gal water <br /> Bento to(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller '&Pump Contractor Other <br /> CI Concrete Pedestal DI enslons,Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP SI Submersible Turbine Other HP Pump Set ft Standing Water Level 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 /> MINIMUM 48 HOU ADVANCE NOTICE <br /> `REQUIRE O P�E/CTiONS-PLEASE CALL(209)953-7697 ) <br /> SIGNED 3 T DATE t, <br /> ckj <br /> 20 <br /> q�l'r <br /> T� <br /> DEPARTMENT USE ONLY � R� <br /> Application Accepted By '14— Date Area 6 1rL►Z!t'lr'Employee ID# A& �vT <br /> Grout Inspection By �� Date t ) "1 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspect on By Date Constructed Well Depth H <br /> COMMENTS��L�� ��,�'11�^, ('Il 'Cir 2C1I�i'leLY Ni. <br /> IF I <br /> PE Sc Receivedhe Amount Date PermiU Invoice# Well ID# <br /> Codes Info By Cash Remitted S e e uest# <br /> J <br /> VVV <br /> EHD 4306 6/11,2019 WELL/PUMP PERMIT <br />