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SAN JOAGUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMWELL/PUMP PERMIT <br />1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT WWW, S' OV.O /e XPIRES 1 YEAR FROM ISSUED <br />JOB ADDRESS w . -h /7 , — <br />CROSS STREET1•�'2—��.., Ii 0 <br />AA <br />1 PARCEL SIZE 1 LAND USE APPLICATION #_ <br />OWNER NAME 2 <br />PHONE r 5_ 'OJ <br />OWNER ADDRESSbdww C <br />CITY/STATE/ZIP 7 (yid <br />CONTRACTOR J _ <br />SUBCONTRACTOR/CONSULTANT <br />PHON <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />11 11 1 R� / PTY/STATE/ZIP <br />LICENSE X C-57 C-61 . D-09 Other NU <br />BILLING MB <br />Pfi/ EXPIRATION DATE <br />TV: OWNER ._:CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELLS PLING: General Mineral/Coliform Bacteria (4391) _ Dibromochloropropane (4392) ._ Arsenic (4393) <br />INTENDED USE DOmestrctPrlvate Irrigation/Agricultural -Industrial -Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name <br />Contact Name or Phone Number <br />-- yry UKK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring{s) # of bonnga Geotechnical of b^^^sa <br />Out-Of-ServicePump�V/SII Out-06Service Well Renewal Cross -Connection Repair <br />_ New Pump p( Pump Replacement Pump Repair -- Raise Well Casinn <br />w r <br />Drilling Method Mud Rotary Air Rotary _ Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom i Gravel Pack/Gravel Size n diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched <br />Steel _ Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 /b bag/5-10gal water) Sand Cement <br />Bentonite (20% solids) Other sack mixl7 gal water <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 Pipe <br />PUMP Submersible Turbine Other HP Pum Set <br />P ft Standing Water Level ft <br />I HEREBY CE TIFY 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 />CURRE ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br />WORKS CO PENSATION L� <br />MIN UM R A4�amrsunTnrc <br />SIGNED <br />PLEASE <br />I'- LL (209 3-7 7� <br />DATE - <br />DEPARTMENT U E C)NLY <br />Application Accepted Date 2/ Area 4 / / Employee ID# <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Date Tj 1 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth <br />COMMENTS <br />VA <br />Received PermiV <br />1 t - . <br />W91511 MIT, <br />ft <br />WELL /PUMP PERMIT <br />_N <br />D <br />I V, C10 <br />2021 <br />