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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 />NON-REFUNDABLE P�GERMIIT+, <br />JOB ADDRESS •` / U( / <br />CROSS STREET <br />OWNER NAME <br />/. <br />www.sl9ov.orcI/ehd <br />tXPIKt5 1 YEAR FROM UATE ISSUED <br />L:(.�&-r4-�L--� y� CITY/ZIP C.� Ii'1 JL% <br />t✓ <br />APN 2-1 r } <br />0 ` -3V2 PARCEL SIZE LAND USE APPLICATION <br />#� <br />PHONE Z J�- '^'j_3l <br />OWNER ADDRESS El/ h t CITY/STATE/ZIP <br />,j_/ <br />CONTRACTOR �I v X 11 S— v c c'A PHONE 3:3 <br />CONTRACTOR <br />CONTRACTOR ADDRESS �/ L / 'CITY/STATE/ZIP �i� <br />SUBCONTRACTOR/CONSULTANT �iC/ C��'`,�z �i✓?�►2 PHONE L� w •� <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br />LICENSE �C-57 C_I C-61 I.I D-09 ❑ Other NUMBER 7�`� EXPIRATION DATE <br />BILLING PARTY: OWNER <CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ 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 Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings I I Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑I Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method+1<Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth7:3l ft Excavation /-I— in diameter ❑ Open Bottom P<Gravel Pack/Gravel Size in diameter <br />_I Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter- in Thickness/Gauge/ASTM Sched7-3c:' ❑ Steel Plastic ❑ Stainless Steel i I Other <br />Grout Seal Depth /Do ft ❑ Neat Cement (94 lb bag/5-10 gal water) >-sand Cement /C�r2 sack mix/7 gal water <br />❑ Bentonite (20% solids) CI Other <br />Grout Placement Method 4<Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By_ Driller ❑ Pump Contractor - Other F4 <br />I Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible❑ Turbine 11 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 />7N�lHO�j%JJR ADVANCE NOTICE REQUIRED FOR,I,Nc/SPEECTIONS - PLEASE CALL (209) 953-7697SIGNED-�7�'P� TITLE 06.�/V6/ - DATEL�� y <br />Application Accepted By 1A Date �bIZ <br />Grout Inspection By (hv ` c rYU Date <br />Pump Inspection By �( Y�,�o 15�-L; L >D,, q_ Date <br />Soil Boring Inspection By Date <br />COMMENTS a i 0 L rj Itl&44 L., In'ejZfW <br />Area Employee ID#�� <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />EHD4316 6/11/2019 WELL /PUMP PERMIT <br />Check#/ Amount <br />Permit/ <br />RIM 0 , M, r Z1W ITM I <br />W"' F F1�MMW17%jMffM <br />LIMEM0%���i <br />• 1 � <br />Omq, <br />EHD4316 6/11/2019 WELL /PUMP PERMIT <br />