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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 jj r 1 ��WWW.s Ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> 7 <br /> JOB ADDRESS �J / j_7 N I Li I I IL D CITY/ZIP A( CY M h( <br /> CROSS STREET Cc I I 1 P i 'tIZ D A�P/N{ 1>i✓—I D-Z'tJYPARCEL SIZE CC LAND USE APPLICATION# <br /> yn p <br /> OWNER NAME D L ( •S /✓1 I ' `1 PHONE <br /> OWNER ADDRESS S CI I e CITY/STATEIZIP <br /> CONTRACTOR \j c�I I-t � I J r 1 1\ N h _"PHONE -7 7�� <br /> CONTRACTOR ADDRESS U I� C X CITY/STATEMP vC1 1 1 CA L 1 J C.5 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE )(c-57 C-61 D-09 Other NUMBER EXPIRATION DATE <br /> BILLING PARRTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) :Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE XDomestic/Pnvate _ Irngatlon/Agricultural Industrial Water Quality Monitoring - Soil Sampling/Characterization <br /> L Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number C <br /> TYPE OF WORK)[New Well i Replacement Well Well Alteration/Modification Other <br /> D Monitoring Well #of bonogs <br /> Well(s) #of wells Soil Bonng(s) Geotechnical #of borings <br /> D Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair JA <br /> New Pum Pum Replacement Pum Repair Raise Well CasingX21 <br /> WELL CONSTRUCTION HENV/ V/N Cp <br /> Drilling Method),Mud Rotary Air Rotary Auger Cable Tool Push Point Other /v V <br /> Proposed Well Depth 3-�O ft Excavation�1 in diameter Open Bottom X Gravel Pack/Gravel Size 114 - in diame pgRNrq�� <br /> Conductorft <br /> Casing in diameter / Conductor Casing Depth r�FNr <br /> Well Casing Diameter C9 in Thickness/Gauge/ASTM Schede 20 Steel APlastic Stainless Steel Other <br /> Grout Seal Depth 1'1 ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement I(: S sack mW7 gal water <br /> Bentonite(20%solids) I Other <br /> Grout Placement Method Pumped L Free Fall Other Fi Retardant/Accelerator(name) <br /> PEDESTAL Installed By X Driller i Pump Contractor Other <br /> Concrete Pedestal I!Dimensions:Width c2 It Length�_ft Thick in i Christy Box 1 Stove Pipe <br /> PUMP XSubmersible Turbine Other HP S Pump Set ft Standing Water Level 1 S G 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 488 HOUR <br /> �1ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASECALL(209)953-7697 <br /> SIGNED_, y TITLE "j ,CC— �7 r��S i Cit it T DATE <br /> i <br /> I � <br /> � O T <br /> �1 <br /> v ` <br /> Cl <br /> k � <br /> DEPARTMENT USE Ory LY <br /> Application Accepted By � Date ( I z Area Employee ID# <br /> Grout Inspection By Dete -Z VZ4LjL SPECIAL Well Permit <br /> Pump Inspection By Date—114.1 1?r'—,Z I -- WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth 0 ft <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Code Info sh Remitted Service Reg ueet# <br /> x ` <br /> EHD 43-06 6/112019 WELL/PUMP PERMIT <br />