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e <br />..s <br />Ir <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 WNM/.SjgOv.Orq/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS J J 7 Y✓ CITY/ZIP y�c7 Y/V� <br />CROSS STREET "/ APN / ' J U 0�/ _PARCEL SIZE 1•4 y LANA USE�AJPPLI <br />OWNER NAME 10A, AAAPHONE <br />OWNER ADDRESS �f,CIITTY/STATE/ZIP <br />%� �}-� �! <br />CONTRACTOR a©•—%��/�1 ^� �J i'� -41 L/'� � > Ys cz� PHONE <br />CONTRACTOR ADDRESS ITYI$TATE/LP <br />SUBCONTRACTOR/CONSULTANT-- PHONE ^ <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE e57 �,V-6i - D-09 <br />BILLING PARTY: OWNER <br /># <br />�. 7 <br />CITY/STATEIZIP 7 <br />11 Other NUMBER D ExPIRATION DATE d <br />❑ CONTRACTOR ] SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING:'—' General Mineral/Coliform Bacteria (4391) - Dibromochloropropane (4392) 1 Arsenic (4393) <br />INTENDED USE omestic/Private , Irtigatien/Agricultural ^ Industrial Water Quality Monitoring - Soil Sampling/Characterization <br />Public Water System <br />Ir different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK [.. New Well r Replacement Well - Well Alteration/Modification F Other <br />MonitoringWeil(s) #of wells _: SoilBoring(s) #ofbodogs Geotechnical #of borings <br />ii Out -Of -Service Well -' Out -Of -Service Well Renewal - Cross -Connection Repair <br />New Pum um Replacement I_ Pum Repair -i Raise Well Casm <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Ci Air Rotary - Auger Cable Tool Push Point - Other <br />Proposed Well Depth ft Excavation in diameter - Open Bottom 7 Gravel Pack/Gravel Size in diameter <br />- Conductor Casing in diameter I Conductor Casing Depth ft <br />Weil Casing Diameter _ in Thickness/Gauge/ASTM Sched J Steel G Plastic 7 Stainless Steel - Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mixR gal water <br />Bentonite (20% solids) '_ Other <br />Grout Placement Method ❑ Pumped C Free Fall ❑ Other - Retardant / Accelerator (name) <br />PEDESTAL Installed By - Driller - Pump Contractor Other <br />I Concrete Pedestal :Dimensions: Width ft Length It Thick in ❑ Christy Box 7 Stove Pipe <br />PUMP 16tbinersiblel-. Turbine a Other HP Pump Set ft Standing Water Level <br />I HEREBY C TIFY 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 />�J UtVAK I MIZN UJ VNLG,T t <br />Application Accepted By /� Date b / 'd 6 Area I Employee ID#_ <br />Grout Inspection By n Date D SPECIAL Well Permit <br />Pump Inspection By r I-SjY(,�' / / c Date I WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE SC Received Chec Amount Date Permit/ Invoice # Well ID# <br />Codes Info By Cash Remitted Service Eequep, <br />8i -77720 <br />EHD 43-06 6/112019 WELL /PUMP PERMIT <br />