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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 />rvUrv-MLI-UNDABLE rl=RMIT <br />WWW.SJgoy.org/ena <br />Amount Permit/Invoice # Well ID# <br />Remitted Service Re uest# <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB A,DDDDRESS/ � <br />7 r <br />w <br />( <br />C ROS A4, <br />CS A4 <br />,��s� t' !7 ) PARCEL SIZE <br />/ o / ! �J O lo I <br />fAY� LAND USE APP'PLLICAT/{ION #�J <br />OWNER NAME L / <br />(,�I S/'� <br />p/�� <br />OWNER ADDRESS /�s'�j <br />-�, <br />1� c l/,(/ �!�� <br />CITY/STATE/ZIP <br />CPHOONNEj(/��/ <br />c�V60f%�!* <br />CONTRACTOR `/�i'/`"�GJrG�//�J/� <br />//- m <br />�� <br />!e-�w <br />PHONE <br />CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />SUBCONTRACTOR/CONSULTANT <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CITY/STATE/ZIP <br />LICENSE n-57 ,fix -61 <br />Ll D-09 E) Other NUMBER <br />S <br />EXPIRATION DATE 7l Z <br />BILLING PARTY: SI OWNER <br />I CONTRACTOR I I SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) 7 Arsenic (4393) <br />INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump AA!ump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION 1-1 <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 [ISteel LlPlastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement 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 Pipe <br />PUMP Vubmersible❑ Turbine ❑ Other HP=,/:,[ L Pump Set 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. 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 />MINI AOANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 95 -7697 <br />SIGNED 'L%i!� i/` % `'�y/L� "� TITLE Ahrl_l� � DATE U ��� <br />J DEPARTMENT USE ONLY <br />Application Accepted By Date434 Area y li Employee ID# <br />Grout Inspection By 4 Date SPECIAL Well Permit <br />Pump Inspection By s Date if WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />ft <br />1Y <br />dT <br />PE <br />Codes <br />SC Received Check#/ <br />Info B Cash <br />Amount Permit/Invoice # Well ID# <br />Remitted Service Re uest# <br />3�iI <br />Opo p <br />7 r <br />w <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />