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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 />ryvn-RtrUNUAttLt t'tKMIT <br />www.sigov.org/ena <br />tXl'IK11=5 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 3911 wL)-r LJool6WDG[ <br />ac A1, <br />CITY/ZIP <br />t-Z)l <br />CROSS STREET 1%i0- DIST J)rUiV G <br />APN 0 IS- 0-"-)g <br />LL, PARCEL SIZE K• 16 <br />LAND USE APPLICATION # <br />OWNER NAME 44-COCCAAAJL, ui44 <br />LLL CA 'J'IAA {ILEA -S <br />PHONE 1,02 — 411 --122a <br />OWNER ADDRESS NST OFF(Ce; <br />Ro,C ?-C/,-r <br />CITY/STATE/ZIP <br />IIJa�)ACLi06� , rA 9S=Sa <br />CONTRACTOR _ NI WI-4G(./n1i, <br />(G,PAWy <br />PHONE%)?-iL-7 <br />CONTRACTOR ADDRESS — _ (�u� kJ-rLcp <br />/NE2 ( U'to <br />CITY/STATE/ZIP <br />-CAC.2AM&r.P CA T_r'j Z L <br />SUBCONTRACTORICONSULTANT _ P C'1 <br />6&r-G-Y,H,tJ1C.41- /N = <br />PHONE `1Ib - 3 71 --CO y J V <br />SUBCONTRACTORICONSULTANT ADDRESS 7IAF" 0-.kCVJ rTVv:.CVi4Gp CITY/STATE/ZIP W07- 14C. AM0VT4_ GA 5'r(AI <br />LICENSE X -C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER %C0 " 9S EXPIRATION DATE 00/71 / Lu 13 <br />BILLING PARTY: ❑ OWNER ❑ CONTRACTOR :SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE 0 Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring X 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 3 # of borings <br />❑ Out -Of -Service Well ❑ 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 15 SU ft Excavation 44 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 Seal Depth 6—SO ft X Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method'A 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 Piae <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. 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 COMPENSATION LAWS. <br />MINIMUM 48 HOUR A VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED. <br />TITLE DATE 11I3�2t <br />n D P RTMENTVV USE ONLY A <br />J�Application Accepted By Date (1 ZOC Area 7 Employee f-� <br />et <br />Grout Inspection By Date ❑ SPECIAL Well Pern>�� <br />Pump Inspection By Date ❑ WAIVER Receive�- <br />Soil Boring Inspection By A �f W Date �l �L— Z& 21% Constructed Well Depth koI, In I <br />�K <br />COMMENTS <br />Permit/ 1� Invoice <br />Service Request # <br />EHD 43-06 6/11/2019 <br />WELL /PUMP PERMIT <br />rn <br />