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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 /> NON-REFUNDABLE PERMIT <br /> sgov.org/ehd <br /> "EXPIRES tL�1��Y"ELAR FROM/DATE ISSUED <br /> Joe ADDRESS G ( <br /> ��Nop(A <br /> Cmr/LP <br /> CROSS STREET h APN $0R Qq PARCESIZE3.3(�LAND USE APPLICATION <br /> OWNER NAME PHONE � l <br /> ) JOWNER ADDRESS N7/-1 CRYISTATEIZIP LCL <br /> CONTRACTOR V /tII r PHONE -0 <br /> CONTRACTOR ADDRESS -�I U CRY/STATE/ZJP / m <br /> � <br /> ��� <<1. <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CrTY�/STATE/ZJP f <br /> LICENSE /C-57 C-61 D-09 - Other NUMBER 1(/69-2(l EXPIRATION DATE �Cl ��__� <br /> BILLING PARTY: OWNER CONTRACTOR - SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:XGeneral Mineral/Coliform Bacteria(4391)XDibromochloropropane(4392)_ Arsenic(4393) <br /> INTENDED USE ^omesticiPrivate Irrigation;Agncultural - Industnal I Water Quality Monitoring - Soil Sampling/Characterization <br /> Public Water System <br /> If giff—t 1—[avnor Wator Sys:o Name C-n.Nana nr Phone Nurrbur <br /> TYPE OF WORK ANew Well - Replacement Well -Well ANeration/Modification Other <br /> -1 Monitoring Well(s) U of wells -1 Soil Bonng(s) a anoor..ys Geotechnical aot Lrmns <br /> "I Out-Of-Service Well -1 Out-0f-Service Well Renewal Cross-Connection Repair <br /> '.New Pump Pump Replacement -1 Pump Repair I Rase Well Casio <br /> WELL CONSTRUCTION <br /> Drilling Method.^ud Rotary w�_1 Air Rotary _Auger 1i Cable Tool l Push Point Other 3� <br /> �l <br /> Proposed Well DepthLft Excavation /_.G in diameter k'G <br /> Open Bottom Gravel Par: ravel Size l��p in diameter <br /> Conductor Casing In diameter / Conductor Casing Depth it <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad r Steel - Plastic Stainless Steel 71 Other <br /> Grout Seal Deptf;�W _ft - Neat Cement(94 16 bag/S-10 gal water) Sand Cement Q r 7 sack rr;4 7 gal water <br /> Bentonite(20%solids) - Other <br /> Grout Placement Method KPumped Free Fall L Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By ADniler _Pump Contractor Other <br /> Concrete Pedestal Dlmenslons:Width___>_It Length ft Thick in . Christy Box Stove Pipe <br /> PUMP Iplsubmersible7 Turbine _i 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 /> MINIM" 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209``)953-7697 7 <br /> SIGNED �.I � ' !/` i TITLE L /� / DATE < CI / <br /> I 7 <br /> A <br /> QUl <br /> DEPARTMENT USE ONLY /,. I}�OF�,MAFNT�N�. <br /> Application Accepted By Z' L— Date S S Area S -/ Employee IDH S -'rTTM.�VN <br /> Grout Inspection By Date SPECIAL Well Permit T <br /> Pump Inspection By JM Date WAIVER Received <br /> Soil Boring Insperlion By Date Constructed Well Depth ft <br /> COMMENTS dJDr <H - In).-h <br /> PE SC SC Received tChecWAmount Date PermlV Invoice# Well 10# <br /> Codes Info 8 Remitted Service Re ue t# <br /> 43 k� --o 1 sWWOWOU <br /> L13 64- i&a 04 1 L,?0 I <br /> 3 s/1 ilS-O I I <br /> r ff <br /> I1-1043-06 611'2019 %WLl 1UMP PI=RMI1 <br />