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AIA211S16 <br />I gZC <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />1`IU1V-f[th U-NUAb Lt rtKMII <br />JOB ADDRESS LZC 5 1" <br />CROSS STREET t-(�' n r11\L) e <br />OWNER NAME <br />APN <br />WWW.SIQOv.O <br />OWNER ADDRESS �/^/r �-'LTJ 1 /�• <br />CONTRACTOR Iy//11e I l.'- Ald?'-1111 rerrc'an <br />-G35 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR/CONSULTANT _ SH✓1'I P (rii AG/`✓L° <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE / C-57 C-61 D-09 Other <br />BILLING PARTY: OWNER ,I' CONTRACTOR <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />CITY/ZIP Jel/lf�[q �� v � t <br />3j- 9! «,P( <br />SIZE 3j- USE APPLICATION # <br />PHONE <br />CITY/STATE/ZIP� / - <br />i ._j L C (� S <br />PHONE <br />2,6^1q— <br />CITY/STATE/ZIP ✓C/G1 / C/(/ 55 Z <br />PHONE Se+ 6S k leve <br />CITY/STATE/ZIP �G+ ✓'? t' ��S q 1. 7✓e <br />NUMBER C' �� UC EXPIRATION DATE <br />SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: _i General Mineral/Coliform Bacteria (4391) _1 Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />❑ Public Water System <br />It different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well Replacement Well I Well Alteration/Modification 1 Other <br />❑ Monitoring Well(s) # of wells i Soil Boring(s) # of borings Geotechnical �� # or borings <br />❑ Out -Of -Service Well I Out -Of -Service Well Renewal Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement I Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method / Mud Rotary ❑ Air Rotary / Auger Cable Tool Push Point Other <br />Proposed Well Depth I r > r ft Excavation ! 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 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 Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller ❑ Pump Contractor Other <br />Concrete Pedestal '-1Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine n 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 />c <br />DEPARTMENT <br />ff USE ONLY,_{—�/ <br />Application Accepted By(),:41"'—� Date l (, I Area Employee ID# <br />Grout Inspection By., Date ❑ SPECIAL Well Permit c�� Fir <br />Pump Inspection By Date 1-1 WAIVER Received <br />Soil Boring Inspection By Date 'ZOqA Constructed Well Depth ft % } <br />COMMENTS �, Oq� `®?% <br />PE Sc Received Chec <br />Codes Info B sh <br />Amount Date Permit/Invoice # Well ID# <br />Remitted Service Request # <br />1 iT 21222 <br />i j /_ 0 I ) <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />