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WE /PUMP ERMIT <br /> SAN JOAQUIN COUNTY E VVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 6232(209)468-3420 <br /> NON-REFUNDABLE FERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> � .. �7 o y <br /> JOB ADDRESS CI7YIZIP i ts`/L_-r✓r i GZ I✓ <br /> CROSS STREET APN% "4& d & <br /> !f •2— PARCEL SIZE LAND USE <br /> - s ^ h USEtyVA'+P,,PLICATI_ON <br /> OWNER NAME X'V� PHONE <br /> -C� <br /> OWNER ADDRESS CITYISTATEIZIP 1,4+-#�/�"s <br /> CONTRACTOR �'e ✓i 'rO C �. PHONE(2C) 523-7-- <br /> �1-`J1rSy<y!L� <br /> 3 <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP - 6'ifj= L -L LS^ GJ <br /> SUBCONTRACTOR/CONS1.LTANT PHONE <br /> SUBCONTRACTOR/CONSt LTANT ADDRESS CITYISTATE/ZIP <br /> LICENSE 15C-57, D C-61 Cl D-09 ❑Other NUMBER �:.5�~ EXPIRATION DATE 2 Jr•✓'G/ <br /> BILLING PARTY: 0 OWNER ❑CONTRACTOR 0 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMP NG:D General Mineral/Coliform Bacteria(4391)0 Dibromochioropropane(4392)0 Arsenic(4393) <br /> INTENDED USE )<Don restictPrivate 0 Irrigation/Agricultural 0 Industrial ❑Water Quality Monitoring 0 Soil Sampling/Characterization <br /> ❑Pubic Water System <br /> If dt ered from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 Ne Well • ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> 0 Mo itoring Well(s) #ofweils ❑Soil Boring(s) ft arbadngs ❑Geotechnical eof borinpa <br /> 0 Out Of-Service Well 0 Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> VNev,Pump ❑Pump Replacement D Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCT1`014 <br /> Drilling Method 0 Mu Rotary 0 Air Rotary 0 Auger 0 Cable Tool ❑Push Point ❑ Olher <br /> Proposed Well Depth ft Excavation In diameter 0 Open Bottom D Gravel Pack/Gravel Size in diameter <br /> 0 Cor ductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Dlam er_In Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth ft 0 Neat Cement(941b bag/5.10 gal water) ❑Sand Cement sack mixf7 gal water <br /> D Be onite(20%solids) 0 Other <br /> Grout Placement Meth d ❑Pumped 0 FrMe Fall D Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Instal Dd By 0 DrillerPump Contractor ❑ Other <br /> ❑Co trete Pedestal❑Dimndnsions:Width_ft Length ft Thick In 0 Christy Box 0 Stove Pipe <br /> PUMP Sut mersibleD Turbine D Other HP Pump Set It Standing Water Level ft <br /> I HEREBY CERTIFY HAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY O DINANCES, STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTT It WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENS kTION LAWS. <br /> MINIMUM 8 HOUR ADV NCE NOTICE REQUIRED FOR ISPI <br /> TIONS-PLEASE CALL(209)953-7697 <br /> TITLE <br /> SIGNED .A/' /.r. TITLE L';' '✓ DATE <br /> REc^^MFNr <br /> y �2 ?020 <br /> A. <br /> lRp <br /> OFPq <br /> NT <br /> DDEPARTMENT U E ONLY p <br /> Application Accept d Byy r Date S j/ Z024 Area / Employee ID# s <br /> Grout Inspecti n By Date ❑ SPECIAL Well Permit <br /> •Pump Inspecti n ByDate ❑ WAIVER Received <br /> Soil Boring Inspecti n By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC leceived Check#I Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Reu t# <br /> 80 0V .Sic-- 41512 <br /> EM043.06 6/11/2019WELL/PUMP PERMIT <br />