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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMITC 1CALL 209 953-7697 FOR INSPECTIONS l� EXPIRES 1 YEAR FROM DATE ISSUED <br /> � C 'S l G✓) IZ D CITYIZIP P\C L�M PC, ; q�j �v�o a <br /> JOB ADDRESS <br /> ) US C3� m <br /> CROSS STREET M I P 47 1 0 K, R V APN U C'5 w ))PARCEL SIZE tI LAND USE APPLICATION# <br /> OWNER NAME 1{e I t //� lO i '�L/1 1\� 1 ✓� LI r s PHONE 1 /—(1��1—C��SO �G w <br /> OWNER ADDRESS 7 C/7 LSI I � L��l-{ w CITY/STATE/ZIP C cI I+ r \ A` I l <br /> CONTRACTOR \'�'I'I,1/ _L) )�\ sY)a PHONE <br /> CONTRACTOR ADDRESS G �G X CITY/STATE/ZIP 1 I r c- A C715 <br /> SUBCONTRACTOR _ PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 C-61 D-09 Other NUMBER t�c� J.> EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:,(General Mineral/Coliform Bacteria(4391)(Dibromochloropropane(4392),—Arsenic(4393)J <br /> INTENDED USE Domesfif/Private Inigation/Agricultural Industrial Water Quality Monitoring r`Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. Water System Name Cnntaa Name or Phone Number <br /> � I <br /> TYPE OF WORK )(,New Well Replacement Well D Well Alteration/Modification Other <br /> D Monitoring Well(s) #of wells D Soil Boring(s) #01 bonngs Geotechnical #of bodngs <br /> D Out-Of-Service Well D Out-Of-Service Well Renewal Cross-Connection Repair <br /> ew Pump Pump Replacement ❑Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodX Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth �?(„C) ft Excavation in diameter ❑Open Bottom )(Gravel Pack/Gravel Size I/q - in diameter <br /> C 3'­1uuu0i ,w;—', ei r iuiw'uuui C,e>iRy ucpui <br /> Well Casing Diameter�in Thickness/Gauge/ASTM Sched C-I'6i i Steel >.Plastic Stainless Steel Other <br /> Grout Seal Depth )C(1 ft Neat Cement(94 Ib bag/5-10 gal water) K Sand Cement 1 sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement MethodK Pumped Free Fall Other Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By X Driller D Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width 2 ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP )G Submersible Turbine Other HP_� Pump Set=5 ft Standing Water Level <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 48 HOUR ADVANCE NOTICE REQUIRED FOR <br /> R) INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE V C C f ��>r �I l fl T DATE <br /> c \ <br /> �i <br /> 4Uf <br /> c <br /> It <br /> 1 <br /> DEPARTMENT USE ONLY <br /> / L U <br /> Application Accepted Hy ��'-�" Date y '� Area ' / Employee Di <br /> Grout Inspection By : t 1_ Date r l q� SPECIAL Well Permit <br /> c� �-o�Ztt it, is/ 727- WAIVER Received{ <br /> Pump Inspection By �ro:L L' _ ` .- Date Y( <br /> Soil Boring Inspection By Date Constructed Well Depth `�1 ® �ftn <br /> COMMENTS (/ <br /> PE SC Received Check#/ Amount erm <br /> Pit/ Cts <br /> at Invoice# N/y (l/y <br /> Codes Info B as Remitted Service Re uest# TAC <br /> r� a ud <br /> i o 30 <br /> 61' a <br /> EHO 43-06 revised 4/14/19 WELL/PUMP PERMIT <br />