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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 www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CROSS STREET) <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />�)CITY/ZIP < v 7� <br />Qjr Q � `> <br />L / "AVN / �j�` 1n Se PARCEL SIZE LAND USE <br />r7APPLICATION <br />�#7 <br />'4:57) f j/ f X /�L/V .L, �7.i�/� % TJ PHONFi'� <br />r (/ pJeJC, CITYISTATE/ZIP�/(J <br />QQy 111�VL�S_._ (�t S f 1 PHONE C�;?b <br />CONTRACTOR ADDRESS C [ol-©. IA -h / L-CQX/K CITYISTATE/ZIP <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS ,I 1 —� CIITTYISTTATTEIZ]IP mod�c , <br />LICENSE -57 D C-61 El D-09 ❑Other NUMBER ! (y/ dL {P EXPIRATION DATE <br />BILLING PARTY: D OWNER D CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING �IyGeneral Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) D Arsenic (4393) <br />INTENDED USE /11)omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: <br />Water System Name <br />TYPE OF WORK4New Well ❑ Replacement Well <br />❑ Well Alteration/Modification <br />❑ Monitoring Well(s) # of wells <br />❑ Soil Boring(s) <br />❑ Out -Of -Service Well <br />❑ Out -Of -Service Well Renewa <br />lvf ew Pump ❑ Pump Replacement <br />❑ Pumo Reoair <br />or <br />❑ Other <br /># of borings ❑ Geotechnical <br />1 ❑ Cross -Connection Repair <br />❑ Raise Well Casino <br /># of borings <br />SEP 3 0 <br />Drilling Method Mud Rotary � Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other "ZQ NM <br />Proposed Well Depth�_ft Excavation �[,?_ in diameter ❑ Open Bottom Gravel Pack/Gravel Size In i <br />❑ Conductor Casing in diameter / Conductor Casing Depth / ft <br />Well Casing Diameter 1Q in Thickness/Gauge/ASTM Sched 4 7� ❑ Steel Plastic ❑ Stainless Steel ❑ Other <br />Grout Sea[ Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) /-)Sand Cement 31 sack mix/7 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 Length ft Thick in ❑ Christy Box ❑ Stove Pine <br />HUMP ASubmersibleo Turbine ❑ Other HPG -'/-- Pump Set !So ft Standing Water Level —Zi5�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 />ARTM ENT USE ONLY <br />Application Accepted By Date Area 41 /ff Employee ID# <br />Grout Inspection By Date 1 PECIAL Well Permit <br />Pump Inspection By Date 2/ WAIVER Received <br />Soil Boring Inspection By <br />Date <br />onstructed Well Depth ft <br />COMME TS <br />001 <br />17 AM <br />PE SC Received <br />eck#/ <br />Amourft Date <br />Permit/ Invoice # Well ID# <br />Codes Info B <br />Remitted <br />Service Request # <br />14346 /yo <br />�'/-300 <br />WPOO40 ! 35 <br />5 1 <br />1,20 06 <br />s <br />W 4 O► 7 <br />EHD 43-06 6/11/2019 <br />WELL /PUMP PERI IT <br />