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Aw�rj'vv <br />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 WWw.sISIOv.Orq/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESS <br />Ji:� <br />/{i / <br />CITYIZIP(,,'&1.1r7-'610 <br />CROSS STREET <br />f <br />APN 06 PA19CEL S E ?f'7 LAND USE APPLICATION # <br />/(r <br />OWNER NAME _A/rtS <br />�I/lt/ <br />" ePL1ciifS <br />[206,(J} )LU)C TIP ONE 219-Q(-'o3y3 <br />OWNER ADDRESS <br />I DID K (:. �me C) O <br />CITY/$TATE/ZJP L.�C� l �� J �� O <br />CONTRACTOR <br />.G�, <br />I <br />�/ p <br />PHONE LO7 <br />CONTRACTOR ADDRESS Z <br />/i[j <br />Ao i" ✓V <br />CIN/STATE/LP /C n O <br />SUBCONTRACTOR/CONSULTANT <br />Q <br />H �C PHONE <br />�Q7`s�f / <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />�V �O 1< <br />� //.' w/ <br />/3 CITY/STATE/AP X' 1"A /' .may {� Iyr / <br />LICENSE )(C-57 <br />C-61 D-09 Other <br />NUMBERb 70 41 EXPIRATION'DDATE ' <br />BILLING PARTY: <br />OWNER <br />CONTRACTOR <br />i SUBCONTRACTOR/CONSULTANT <br />DoMEsnc WELL SAMPLING: ! General Mineral/Coliform Bacteria (4391) i Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monit� J''fi�g 7C8oil Sampling/Characterization <br />Public Water System Z. w "H l7/Og - ZO ]- Z 70Z <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modi cation Other <br />Monitoring Well(s) # of wells X Soil Boring(s) 3 # of borings Geotechnical <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br /># of borings <br />Drilling Method Mud Rotary 1 Air Rotary Auger <br />/� Cable Tool Push Point Other <br />Proposed Well Depth_�ft Excavation /�I in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />I Conductor Casing in diameter/ Conductor Casing Depth It <br />Well Casing Diame m Thickness/Gauge/ASTM Sched I Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft ?(Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped &Free Fall *40ther Retardant /Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width It Length It Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP 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 />MIN M 48 HOUR ADV i CEyNfQ TICE REQUIRED FOR I f7C�PE N PLEASE CALL (209) 9 -76?7 <br />SIGNED / v d4 V[H �— TITLE / �+ �N!(/ DATE L Z / <br />DEPARTMENT USE NLY <br />Application Accepted By Date <br />Grout Inspection By Date t0i l I It <br />Pump Inspection By Date <br />Soil Boring Inspctia By _ <br />COMMENTS. I a <br />0, 6- itio� <br />Date <br />Area `r I Employee ID# F 67 <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Wel) Depth f <br />N <br />L'�®►1./:�J�z����Ti�i7��1�1�'►fJi.1:i/,i: <br />Ji:� <br />EHD 43-06 6/112019 <br />WELL /PUMP PERMIT <br />1414 7. <br />F/VFA <br />2 8 2p2� <br />ti�V N7Y <br />A,ctua <br />