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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 />111vllr-r%erunUAt5Lt rtltMIT f� (� C <br />www.slgoy.org/ehtl EXPIRES 1 YEAR FROM DATE ISSUED <br />C- Z 7,JOB ADDRESS r F` .J�SS� I-� Z�l'l -f rY/ZIP oC�-��.r\ <br />CROSS STREET APN ) -A 3L —OPARCEL SIZE 5 S d LAND USE APPLICATION # <br />OWNER NAME �1'2 �l <br />�� V r <br />Date Permit/Invoice # Well ID# <br />Remitted S Ice Re uest # <br />PHONE( <br />L4 <br />OWNER ADDRESS �7 C <br />lM <br />r — <br />i./ (` t� i'1 /' ✓j <br />CITY/STATE/ZIP <br />CONTRACTOR /J p, \ ll /A <br />,;N <br />PHONE T <br />CONTRACTOR ADDRESS r(0 Z .} <br />,\'A-< } v1 �, t,ti1 C. <br />CITY/STATE/ZIP <br />C , C,4 `1 C Jl L{ U <br />SUBCONTRACTOR/CONSULTANT <br />S0.n-f- C`5 <Lb,:��, <br />PHONE SC•.vr�C c.1 c�ln��(�, <br />SUBCONTRACTOR/CONSULTANTADDRESS <br />CITY/STATE/ZIP <br />LICENSE ' C-57 J C-61 <br />D-09 Other <br />NUMBER '„ V G `k <br />EXPIRATION DATE <br />BILLING PARTY: 1) OWNER <br />- CONTRACTOR <br />SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: D General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) _ Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial 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 Well Replacement Well ' Well Alteration/Modification Other <br />Monitoring Well(s) # of wells i Soil Boring(s) # of borings Geotechnical I # of borings <br />Out -Of -Service Well i Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump U Pump Replacement i Pump Repair Raise Well Casino <br />Drilling Method Mud Rotary C Air Rotary k Auger Cable Tool Push Point Other <br />Proposed Well Depth 5"- 7u' ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft X Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />D Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP " 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 />R <br />QEkARTMENT USE qNLY <br />Application Accepted By j Date Cir <br />Grout Inspection By V <br />4LY <br />Date <br />Pump Inspection By Date <br />Soil Boring Inspection By � Date <br />COMMENTS <br />Area Employee ID# 61 <br />S ECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC Received CheckAmount <br />Info B <br />Date Permit/Invoice # Well ID# <br />Remitted S Ice Re uest # <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />