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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 PERMITWWW. 7Y/ 11P [VI 4 YNjS. oV.Or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> 21 1 o Dl� (Z � <�I-L <br /> JOB ADDRESS 6t7t-f�i rJ / � (J(�, <br /> CROSS STREET C_11.0,:!1%i' f I /5 VJ t� APN O~ MEL SIZE r LAND USE APPLICATION# <br /> u I,r b� �{J 2_V1, 7 I �- LAoo0 <br /> OWNER NAME � � � Y hl l /'t V� C Z- PHONE `` � <br /> OWNER ADDRESS I C J CITY/STATE/ZIP L UA l <br /> CONTRACTOR '�`�)-r'I ✓ `V `✓�I PHON�E�L( r -`( <br /> CONTRACTOR ADDRESS J� 1 `l"'� CITY/STATE/ZIP ��`��f 6�,{ <br /> SUBCONTRACTORICONSULTANT 1\\ "� PHONE_ <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP / <br /> LICENSE /,-57 C-61 ! D-09 Other NUMBER l.0 XPIRATION DATE <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:A-General Mineral/Coliform Bacteria (439 1)x Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE f Domestic/Private `, Irrigation/Agricultural Cl Industrial D Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well ❑ Replacement Well i I Well Alteration/Modification 11 Other <br /> I Monitoring Well(s) #of wells ❑ Sail Boring(s) #of borings a Geotechnical_ #of borings <br /> i Out-Of-Service Well ❑ Out-Of-Service Well Renewal [.I Cross-Connection Repair <br /> New Pump a Pump Replacement ❑ Pump Repair -i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary ❑ Air Rotary Auger L) Cable Tool Push Point Other <br /> Proposed Well Depth b ft Excavation , in diameter ❑ Open Bottom Gravel Pack/Gravel Size in diameter <br /> I Conduct r Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter in Thickness/Gauge/ASTM SchedJ0P-Z 1 ❑ Steel Xpl,stic I Stainless Steel D Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) i Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method CI Pumped ❑ Free Fall 1.1 Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller L Pump Contractor n Other <br /> [i Concrete Pedestal ODi ensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> -- -— - <br /> [PUMP II Submersible❑ Turbine j 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 /> MINI U UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209 95 -7697 f` ` <br /> SIGNED _ TITLE f/( I I"VY DATE v <br /> 9` <br /> TF I <br /> S <br /> BA <br /> E/\ U/Pj C OL N4y <br /> N D p T4 <br /> DEPARTIM ENT USE ONLY <br /> Application Accepted By Date S s Z"`'� Area Employee ID# P/11 <br /> Grout Inspection By Date 5 1 S 2�2J SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info j3y, Ca h Remitted Service Request# <br /> �yaa SZD <br /> q3`i I ►y.s 57S1_2 D <br /> 9301;k 7� S <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br /> � 1o8219It�� <br />