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WELL/PUMP PERMIT le=Y <br />SAN JDADUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />WWW.S Ov.U[/ehd <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 66 <br />CITY/ZIPrfi <br />S <br />CROSS STREET Aq, <br />R,^[� Z <br />APN 'c -)L1? -)j �+`� �`-' PARCELSIZE 103 LAND USE A�PPPLIICC�ATIONiiilll# <br />OWNER NAME <br />/ <br />P H/O'N�EtQ/y-�3yL/ qZ — C.J 1-9- 7 <br />OWNER ADDRESS <br />CITY/$TATE/7J <br />t4 qt � <br />CONTRACTOR <br />PHONEQ?> Cq 3,11`'0 <br />CONTRACTOR ADDRESS &12042hCITY/STATE/ZIP <br />SUBCONTRACTOR/CONSULTANT <br />4A <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE A C-57 C-61 D-09 <br />CI ISTATE/ZJP <br />Other NUMBER <br />EXPIRATION DATE / • . <br />BILLING PARTY: _ OWNER <br />CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SA PLING: _ General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) - Arsenic (4393) <br />NTENDED USE DomeSl c/Pnvate - Irrigation/Agricultural Industrial - Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contac) Name or Phone Number <br />vvunn lvew vveu Kepiacement well Well Alteration/Modification - Other <br />Monitoring Well(s) # of wells Soil Bodng(s) # of bonng5 Geotechnical # of borings <br />Out-Of-Service1dell Out -Of -Service Well Renewal _ Cross -Connection Repair <br />New Pump (Pump Replacement - Pump Repair Raise Well Casino <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 in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Sched - Steel Plastic - Stainless Steel Other <br />Grout Seat Depth ft Neat Cement (94 /b bag/5-10 gal wafer) Sand Cement sack mixR 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 Lenolh It Think <br />PUMP X Submersible Turbine Other HP _I Pump Set-1YU 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. 1 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 CO PENSATION LAWS <br />MI/ OUCyEJN/OJTICE REQUIRED FOR <br />It,SP2 PLEASE CALL (209) 5 76 7 <br />SIGNED f ii/�i�f� TITLE I'll DATE �� <br />m <br />D <br />C3 <br />A <br />m <br />N <br />=� �y - uate v K Area 11 / -L Employee ID# 1LP'L <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />-4-01-0570 <br />SC Received <br />Info By <br />eck# Amount Date Permit/ <br />Remitted Service Re uest # Invoice # Well ID# <br />A17AI <br />7 <br />EH043-05 6/112019 <br />WELL /PUMP PERMIT <br />