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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-REFUNDA13LE��PERMIT ] www.s ov.or /ehd tEXPIRES 1 YEAR FROM DATE ISSUED <br /> 9 . J JfE1�/4N T� Q ye/q/Npd C�/r ' 9CZ�0 w <br /> JOB ADDRESS �C p CIN/ZIP m <br /> CROSS STREET 6/0 13k ue4 L/� APN 407--4/c PARCEL SIZE 54C-t D <br /> �c n LAND US�EAPPdLIC)ATION# <br /> OWNER NAMEdf/St <br /> OWNER ADDRESS Y i7 77 ��7�T �(?14,f-A,,- {r/�/ted• CITYISTATE/7JP />•(i {/0 41 �2/* <br /> CONTRACTOR ��}-t1 e i�-.`t -(411,i 1A.1 i PHONE/J%/] `�,y',�,2—v//�// I <br /> CONTRACTOR ADDRESS /V i f y 6,es UX i CITY/STATE21P N�K/}i(iry • / 3719 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS:7 �CIITTYISTAT�E//ZIP 'J <br /> LICENSE XC-57 C-61 ^ D-09 :� 7^ <br /> Other NUMBER 877✓4 EXPIRATION DATE • <br /> BILLING PARTY: LJ OWNER U CONTRACTOR L SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)-_ Dibromochloropropane(4392)C Arsenic(4393) P"IWEN T <br /> INTENDED USE Domestic/Private D Irrigation/Agricultural D Industrial Cl Water Quality Monitoring D Soil Sampling/Characterization C: r^•1IG� <br /> C Public Water System l�C E►D <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well 7 Replacement Well D Well Alteration/Modification ❑Other OR 2"^S <br /> 2020 <br /> #of borings #of borings <br /> D Monitoring Wells) #of wells D Soil Boring($) ❑Geotechnical <br /> ❑ Out-Of-Service Well D Out-Of-Service Well Renewal D Cross-Connection Repair SAN <br /> ❑ New Pump ❑Pump Replacement 7 Pump Repair C Raise Well Casing EN IRONNNENTUNTY <br /> WELL CONSTRUCTIONHEA H DEP AL <br /> Drilling Method1KMud Rotary C Air Rotary 7 Auger U Cable Tool C Push Point C Other ARTMENT <br /> Proposed Well Depth VLO0 ft Excavation IL-9 diameter 7 Open Bottom KGravel Pack/Gravel Size4in diameter <br /> I i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter(in Thickness/Gauge/ASTM Sched C Steel XPlastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth /60 It n Neat Cem nt(94 lb bag15-10 gal water) n Sand Cement ixf7 sack n gal water <br /> D Bentonite(20%solids) C Other I <br /> Grout Placement Method , umped C Free Fall U Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 17 Pump Contractor jQC_Other <br /> LJ Concrete Pedestal uDimensions:Width ft Length ft Thick in L Christy Box L Stove Pipe <br /> PUMP I I Submersible I 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 COMPE SATION LAWS. <br /> MINI 48 HOUR DVANCE NOTICE REQUIRED FOR INSS/SECTIONS-PLEASE CALL(209)9 3-7697 <br /> SIGNED <br /> TITLEy/�� DATE <br /> r •4— •�. <br /> L <br /> I� <br /> . I <br /> 1 <br /> a DEPAJtTMENT USE O LY <br /> Application Accepted By i/ Date ?_ Area Employee 6# vb�� ii 11 <br /> Grout Inspection By Date� ❑ SPECIAL Well Permit <br /> Pump Inspection By Date G WAIVER Received <br /> Soil Boring Ins action By D to Constructed Well Depth ft <br /> COMMENTS ��� S a A r� 41 CL <br /> PE SC Received Chec Amount Date Permit! Invoice# Well ID# <br /> Codes Info as Remitted Service Re uest# <br /> (i3 6 4 73 231V vt� U(au <br /> r, ) `- 3 y <br /> �I 6h <br /> EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />