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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />t/ <br />fanA Rd CINIzIp <br />• :Z_ <br />CROSS STREET <br />OWNER NAME I� f/� �n(^1 <br />APN PARCEL SIZE LAND USE�JAPPLICATION <br />(i� PHONE(`OD— ✓i✓✓� <br />�1 <br />OWNER ADDRESS WIVN <br />/�I�/V <br />C)a1/�-/I I" U. CITY/STATE/7JP �✓ <br />1Ov/ I <br />' /� �% <br />� <br />CONTRACTOR L,t' v`//'G7 <br />j t �� CX . <br />CONTRACTOR ADDRESS 2`-I 1 <br />��7I ��/1 /�f-� <br />/ �It./Y� ,/•l�l.Q. �' n (P�H�O/N�E � I� <br />ll IV \� ��ly / Jy i7 ' CITY/STATE/LP �. UOUO! 1. I5. ao <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CIN/STATE/LP <br />$3 4488 <br />LICENSE I%C-57 ❑ C-61 <br />_ D-09 Other NUMBER EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4 391) 1 Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE omestic/Private r- Irrigation/Agricultural Industrial p Water Quality Monitoring - Soil Sampling/Characterization <br />Public Water System <br />If dtferent from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well Replacement Well Well Alteration/Modification Li Other <br />I Monitoring ln/ep;;) # f wello coil Rorinnrst #of bonngs Geotechnical <br />Out -Of -Service Well Out -Of -Service Well Renewal i Cross -Connection Repair <br />ylQew Pump ,] Pump Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br /># of borings <br />Drilling Method Mud Rotary ❑ Air Rotary Auger Cable Tool Push Point Other & C <br />Proposed Well Depth ft Excavation in diameter i i Open Bottom Gravel Pack/Gravel Size in <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel C Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/`r10 gal wafer) Sand Cement sack mixr7 gal water <br />Bentonite (20% solids) D Other <br />Grout Placement Method Pumped [: Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller D Pump Contractor ✓ Other <br />Concrete Pedestal Li Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP_3 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 24 HOYR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9531-7697 <br />SIGNED _ TITLE l/u'Y G 1-�� �-t �-L- DATE <br />AAMR ENT E O)N LY <br />Application Accepted By to l <br />Grout Inspection By Date <br />.i <br />Pump Inspection By , f r':' -V -&c �rit�6 �. Date <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Y�ENr <br />26 2019 <br />J/j* N'VNry <br />Area Employee ID� <br />PECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />EHD 43-06 8/01/16 77 8, 12 - <br />WELL /PUMP PERMIT <br />