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r 14 WELL/PUMP PERMIT <br />SAN J6AQUIN CbUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE/ PE�jRNT www.sjgov.org1end hAPIKhb 9 YEAR FRROM�LATE ISSUED <br />JOB ADDRESS 1vy eer w/ 17 '9" CITY/ZIP 7 � `�J/ <br />3 <br />CROSS STREET t7 /�� APN ZZ Z31 00.5 PARCEL SIZE �.3`f LAND USE APPLICATION # A1_111#_ <br />OWNER NAME D/ �/� "1'" �� 1464-� PHONE _20 <br />OWNER ADDRESS (� ry �� D� / ' / /� CITY/STATE/ZIP <br />CONTRACTOR �/ G�f Z2 9 ,l IA4214- ��J�/�Q��f "/ G PHONE <br />CONTRACTOR ADDRESS �� l ` l ��l��P✓s /�� CITY/STATE/ZIP <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE ?"C-57 ❑ C-61 ❑ D-09 ❑ Other <br />BILLING PARTY: -OWNER I CONTRACTOR <br />PHONE <br />/CITY/STATE/ZIP I <br />NUMBER( "J 7� /�� UP EXPIRATION DATE ; / d <br />SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: 1 General Mineral/Coliform Bacteria (4391) 1_ Dibromochloropropane (4392) 1 1 Arsenic (4393) <br />INTENDED USE �mestic/Private ❑ Irrigation/Agricultural ❑ InduJ�trial 11 Water Quality Monitoring El Soil Samplin /Characterization <br />El Public Water System /I/ A- � �� <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 -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />,WMew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing PAYMENT <br />WELL CONSTRUCTION RECEIVED <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 a1 (r, 7 inter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft S <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ElPlastic LiStainless Steel �AN JQAQUIN COUNTY <br />`�j�JIR9NMENTAL— <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement HEALZ IVIDEP -AwR,j4Wjer <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 i4L ft Length ft Thick in El Christy Box ❑Stove Pipe <br />PUMP Y Submersible ❑ Turbine ❑ Other HP Pump Set1640 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 />MINIMUM OU AD N T REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95 7697 <br />/� ` \ ,' <br />SIGNED 9/ �� ' ✓fGG TITLE e%jl14-e DATE <br />T <br />m <br />D <br />v <br />v <br />m <br />m <br />N <br />V7 <br />Se <br />o fiL LLGL// til ioa _ <br />Application Accepted By .� 1�1 Date a6 h l Area Employee ID#A <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By 3L\ m <br />Date�Sjl. UvAl ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS yQ-iI12e1"AlD 1^1FUS% or 33 <br />PE <br />Codes <br />SC Received <br />Info 'ftByj <br />Check#/ <br />Cash <br />Amount Permit/ <br />Remitted at Service Request # Invoice # Well ID# <br />W39 -c) <br />V 1 s w <br />►s 3U <br />1 <br />EHD 43-06 6/11/2019 (�„ $� rY` j �} Q�S U (� WELL /PUMP PERMIT <br />