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r <br /> 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 �f 1 www.s ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 7 J(017 41U r r1Q CITY/ZIP /�C�A/y 0, <br /> � <br /> j D <br /> CROSS STREET qO /2!�3�UA5 L 1-A L APN 407-510-30 PARCEL SIZE v 4Gt'LAND USE APPLICATION#) / A <br /> OWNERNAME �✓IN /H/LL�PJ PHONt /�L^cL —CS w <br /> OWNERADDRESS It cS�7 lKf}ST J/ilfff}-Nr ' CITY/STATE/ZIP <br /> IP -0rA2-P <br /> e 1 <br /> CONTRACTOR e( o —(Po-s T��IC�/. PHONHp�/%/� ,yam //ai <br /> CONTRACTOR ADDRESS (� ze-, /X L CIN/STATE2IP /y OK/t�lGl�' 3719 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS �nC IITTAY/`STATlEIZIP <br /> LICENSE IXC-57 n C-61 F D-09 fl Other NUMBER 7y771i EXPIRATION DATE 71-5 <br /> BILLING PARTY: U OWNER U CONTRACTOR L SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:[7 General Mineral/Coliforrn Bacteria(4391)C Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural D Industrial ❑Water Quality Monitoring D Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORKNew Well 7 Replacement Well ❑Well Alteration/Modification 0 Other <br /> 0 Monitoring Well(s) #of wells U Soil Boring(s) tt of ti-rigs 0 Geotechnical tt of bo nqs <br /> 0 Out-Of-Service Well D Out-Of-Service Well Renewal D Cross-Connection Repair <br /> U New Pump 0 Pump Re lacement -1 Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method KMud Rotary C Air Rotary 7 Auger ❑Cable Tool C Push Point C Other <br /> Proposed Well Depth DD ft Excavation_Z6_in diameter 0 Open Bottom XGravel Pack/Gravel Size 9 in diameter <br /> I <br /> i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter(in Thickness/Gauge/ASTM Schad 7 Steel XPlastic U Stainless Steel 77 Other <br /> Grout Seal Depth 160 It nNeat Cem nt(94 Ib bagl5-10 gal water) -1Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) C Other <br /> Grout Placement Method >6umped C Free Fall ❑Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor je,Other <br /> Li Concrete Pedestal L:Dimensions:Width ft Length ft Thick in L Christy Box I_ 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 <br /> INS CTIONS-PLEASE CALL(209)9 3-769777 <br /> SIGNED <br /> TITLE /' DATE <br /> �Eo <br /> 0 <br /> FNS,a0 <br /> FNT <br /> DPA,RTMENT USE ONLY <br /> Application Accepted By Date �/ w Area ` Employee 10# <br /> Grout Inspection By Date L CL ❑ SPECIALWell Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring I s ection By Date (Constructed Well Depth ` ft �� <br /> COMMENTS KL( VA 1 (�./ ( ./S• <br /> PE SC Received heck#/ Amount Date PermiU Invoice# Well ID# <br /> Codes Info rW Remitted ",arvice Re uest# <br /> 3 a 3'23Itio WV VV5 <br /> I 'D —'* y� d J 3�j23� UJ <br /> 93`11 — 1 S ti �u IOID <br /> EHO 43-06 6/11/2019 WELL/PUMP PERMIT <br />