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p�V <br />I <br />I <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NDN-RFFI1Nr1ARI r. PERMIT www_siaav_ora/ehd r-- EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS L CITY C.2 2 l --S <br />CROSS STREET V' '` AP J oV W�+�r ,,I} PARCEL SIZC Al LAND USE APPLICATION # /L) <br />OWNER NAME V `^ d 7 O r., PHONE 'S O <br />ER ADDRESS T I 1/,�O Q S u/ t CRYISTATE/LP <br />CONTRACTOR V WL e po � � PH/ONE .1110 <br />CONTRACTOR ADDRESS v q (4 it ,l CRYISTATE/Z1P V <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS / CI /ST1T�E P 1 <br />LICENSE C -57A C-61 D-09 Other 1 NUMBERZ� W V XPIRATION DATE � I <br />BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WE L AIIII General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED US Domestic/Private Irrigation/Agricultural Industrial 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 Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Bonng(s) p of borings Geotechnical n of borings <br />Out -Of -Service Wellrvice Well Renewal Cross -Connection Repair <br />NewPump Pump Replacement Pump Re air R Ise Well Casing <br />WELL CONSTRUCTION r Y P U <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 <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/S f0 gal water) Sand Cement sack mixf7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Len, <br />g ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALI ANIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MIN)MUM 48 HQldje ADV E� TICE REQUIRED FOI�I�SPE �IOI�,S�PL S� CALL (209) j�97/� <br />SIRNEn / /f �� TITLE n ✓ 10' V vI DATE ✓7 / <br />DEPARTMENT YSE ONLY <br />Application Accepted By 1��G� Date <br />Grout Inspection By Date <br />Pump Inspection By Date q(2I Z Z-( <br />Soil Boring Inspection By Date <br />COMMENTS / I I cav n�jfii U - A po l i. W A <br />W <br />M G <br />RFq yM <br />4110?s FO <br />Area e Slt11 JY1 Employee]D# AG <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed WFII Depth ft <br />EHD43-06 6/11/2019 <br />WELL /PUMP PERMIT <br />T MFNT <br />