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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 "W.sjgov.org/ehd I EXPIRES 1 YEAR FROM DATE ISSUED In <br /> JOB ADDRESS ( J+V`� CITY/LP i G RI <br /> CROSS STREET y;�' n p ( �AfPINN Q!5 `"�� PARCEL SIZE it D L2 LAND US APPLICATION# IM <br /> A <br /> OWNER NAME , ` l J b4 ` PHONE (D` �N,+ <br /> OWNER ADDRESS �,� Q II C r CITYIST 6� Q <br /> CONTRACTOR �/,j/. 1 �_ I�PHO IJV <br /> Itn <br /> CONTRACTOR ADDRESS V CnY A Y rC' <br /> SUBCONTRACTOR/CONSULTANT_ PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITTYIISTATEZP <br /> LICENSE C-57 k-61 D-09 Other <br /> �� NUMBE Ile(d.b EXPIRATION DATE Ck <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WEL PUNG: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> [L-ENDEDUSE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System .vl <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Seng W II Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum Pum Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter C <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal wafer) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) Other r'\ <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) 1 <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft LqRQth ft Thic in Christy Box tove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level%LLft <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 /> MIN UM 48 HOUR ADVANCENOTICE REQUIRED FOR IftSPECTIONS <br /> O-PLEASE CALL(209)�3- W <br /> SIGNED /- TITLE CIA L ( T 1 I f 1 It I DATE <br /> EMT <br /> EIVED <br /> 13 2021 <br /> 6t Lj�+ UN <br /> DEPAR MENT USE ONLY H ENVIRONMENT AL <br /> L <br /> ��—/�—LiZ- Date 7/ 7I Area C Em Ty DFP <br /> Application Accepted By Employee ID# ARTMENT <br /> Grout Inspection By Date_ _ SPECIAL Well Permit <br /> Pump Inspection By L Date-A( �( � �► WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Check#/ Amount Da Permit/ Invoice# Well ID# <br /> Codes Info a Remitted Service litequest# <br /> s:-o <br /> EHD 4306 6/1112019 WELL/PUMP PERMIT <br />