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VZ+ i� lu, , <br />4; <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />IVUI .M"UNUABLE I`nERMIT /i <br />JOB ADDRESS i Dcr 1 - <br />CROSS <br />CROSS STREET i- Vi F er <br />OWNER NAME <br />1 APN <br />WWW.Sjgov.o <br />d EXPIRES 1 YEAR FROM DATE ISSUED <br />C"/ZIP r�r�� ! cc, ci Z �� <br />� G T uc'r3 <br />PARCEL SIZE LAND USE APPLICATION # <br />PHONE <br />OWNER ADDRESS D �2 r/) kA 1 ` C\L CITY/STATE/ZIP <br />CONTRACTOR i % �n/;1 f f/�.f11 (�l�rr�}�-n) i�C/�.�j PHONE Z <br />1 l <br />CONTRACTOR ADDRESS CI C' /1(l i+f l r �i' 1/�l' 1 �/ CITY/STATE/ZIP , L/T / - 7 Z �o <br />SUBCONTRACTOR/CONSULTANT /✓!A PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS ""/1A <br />LICENSE / C-57 ❑ C-61 D-09 Other <br />BILLING PARTY: ❑ OWNER /CONTRACTOR <br />CITY/STATE/ZIP A /[/ / <br />NUMBER C61 <br />U EXPIRATION DATE <br />SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) U Dibromochloropropane (4392) C Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural ] Industrial I Water Quality Monitoring / 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 i Replacement Well I_I Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of b°nngs / Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />'i New Pump ❑ Pump Replacement I I Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotaryrr C Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation_ in diameter r' Open Bottom i Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched i Steel I Plastic i 1 Stainless Steel Other <br />Grout Seal Depth ft /f Neat Cement (94 lb bag/5-10 gal water) I Sand Cement sack mixl7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method 1 I Pumped Free Fall i Other I Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal i Zimensions: Width ft Length ft Thick in ❑ Christy Box I Stove Pipe <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. 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 HOUADV NCE N TICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />v <br />SIGNED / � TITLE C7000 ,�i9rtcla r DATE <br />DI$P/jRTMENT US <br />Application Accepted By <br />Grout Inspection By Y <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Date l• U <br />Date <br />Date <br />Date <br />❑ SPECIAL Well Permit <br />I WAIVER Received <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />SC Received <br />Info B <br />Amount Date Permit/Invoice # Well ID# <br />Cash Remitted Service Request # <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />