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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 .6232 (209) 468-3420 <br />NON-REFUND"LAXERMIT t/ www.sjgov.org/ehd_ EXPIRES 1_Y rrrFROM DATE ISSUED <br />JOB ADDRESS l�/ �' •CV� �j CITY�/ii 7 V [� 7Ll�t <br />CROSS STREET Esc 5(Jr� II��fjC��nAPN�o71q D�b PARCEL S¢E'If�-/ LAND YSE APPLICATION #-7p <br />OWNER NAME " 1 t t / {C _ /� r_\//y��PHQ 1) / p L/- <br />0 <br />/� JJa <br />OWNER ADDRESS 1 t ST E iI f _ f7c; <br />CONTRACTOR R C _ _ PP �tYlo <br />IV Itj <br />CONTRACTOR ADDRESS _ 0 "" _ CITYISTATE/ZIP <br />SUBCONTRACTOR/CONSULTANT ( A <br />///��� PHONE FV <br />SUBCONTRACTORICONS\U�L('TANT ADDRESS JiI SJATERIP I�%J,-1,/--''}--//�,—_ <br />LICENSE C-57 ,J \ GE' 0-09 `, Olhef_ NUMBEROCJ. 1/�Y/11l/Y/7 EXPIRATION D €'�-�= <br />BILLING PARTY: OWNER �( CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WE L SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />[LN_:::USE/-,Domestic/Pnvate Irrigation/Agricultural Industrial Water Duality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If 01—M Iron Owner. Water System Name — Cor.:ad Name or Phone Numi.r- — <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Wells # of wells Soil Bann s # ri tmngs Geotechnical <br />Out -Of -Servide Well Y OutO1-Servlce Well Renewal Cross -Connection Repair <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other ' <br />Proposed Well Depth n Excavation _ in diameter Open Bottom Gravel PadJGrave! Size <br />Conductor Casing in diameter I Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel <br />Grout Seal Depth ft Neat Cement (94 16 bag/5-10 gal wafer) Sand Cement <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width _ It Leng( <br /># of bonngs <br />N <br />! <br />In diameter <br />C <br />Other <br />sack mi gal water <br />n Ihick In GhnStVboX <br />PUMP /% Submersible Turbine Other ___HP y,,1' Pump Set__ ft Standing Water Level I ✓ � ft <br />,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 />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED <br />c•...,�.. TmcFOR R SPE PLEASE CAL (209))57J697 <br />YAIIroM,1;' 1 <br />DEPARTMENT�ONLY /y - <br />Application Accepted By c— /"�L Date 7 1 � Area—1 / _ Employee ID# <br />Grout Inspection By _ Date SPECIAL Well Permit <br />Pump Inspection By O , 121 WAIVER Received <br />Soil Boning Inspection By _ _ Date _ _ pCon'struucctted W Depth _ ft <br />COMMENTS VQ'Z�SSC—. <br />EHD47-06 6/11/2019 WELL !PUMP PERMIT <br />ieD_ 78.,VFZ ED <br />08 ?021 <br />QUIN <br />E01gRTM47. <br />