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SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ELL/PUMP PERMIT <br />1668 EAST HAZELTON AvENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABL PERMIT www Sgov.orglehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CITYMP <br />ROSS STREET AP O� i PARCEL SME J, 01 <br />LAND USE APPUCATIONa} <br />7WNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR/CONSULTANT <br />PHONE ^ <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />/STATEfZyP <br />LICENSE JC C-57 ❑ C-61 0-09 U 4bmcaEXPIRATION DA <br />Other NUMBER I a0 <br />BIWTEN6 PARTY; OWNER C CONTRACTOR 7 SUBCONTRACTOR/CONaut-TANT <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) _- Dibromochloropropane (4392) -1 Arsenic (4393) <br />tNTSNOGO UeE D-mestirJPrivete .; ImgaUon/AgricvlturBl Industrial r, Water QualityMonitoring G <br />Public Water System 9 SaT Sampfmg/Character¢afion <br />It different from Owner. Warm System Neme <br />TYPE OF WORK <br />naw even _ Replacement Well 7 Well AlterallDn/Modificalion Other <br />Monitoring Well(s) # of wells C Soll Borings) a of borings ❑ GeolechniCal n of borings <br />Oul-OfSenrice ykil Out -Of -Service Well Renewal Cross-ConneWon Repair <br />New Pump 7 ( Pump Replacement - Pump Repair Raise Wall Caslnn <br />'Drilling Method Mud Rotary C Air Rotary Auger 7 Cable Tool r, Push Point : Other <br />Proposed Well Depth fl Excavation in diameter _ Open Bottom ❑ Gravel Padk/Gravel Size <br />Conductor Casingin diametei <br />In diameter / Conductor Casing Depth ft <br />Well Casing Diameter —in Thicimess/Geuge/ASTM Schad r. SteelPlastic D <br />Grout Seal Depth 13 Stainless Steel = Other <br />P It = Neat Cement (94 /b bag/5 109.1 water) Sand Cement <br />Bentonite (20% solids) Other sack mW7 gal water <br />Grout Placement Method Pumped , Free Fail _ Other L Retardant r Arrmt—r . --- I <br />Installed By Driller ^_ Pump Contredor Other <br />7 Concrete Pedestal uDlmensions: Width ft LenDU <br />in _ Christy Box Stove Pine <br />rI= 4 Submersible^ Turbine = Other HP Pump SeL R Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE rWITH 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 />WORK PIS COMPENSATION LAWS , <br />Applicalion Accepted By <br />Grout Inspection By 1� <br />Pump Inspection By _ .` ,► / ` -'��— <br />Date <br />Date <br />KCvr <br />Fivie® <br />U 8 2021 <br />QUIN co <br />DIVMFA—til v7 Y <br />me r MEIV T <br />Employee <br />PECIAL Well Permit <br />WAIVER Recalvad <br />Yr -U rPUPAP PERMIT <br />