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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 />NUN-KEFUNDABLE PERMIT <br />7 / ) www.sjgov.Org/ena tXPIKtb IYEAR FROM <br />�jUATE ISSUED <br />JOB ADDRESS Zig L"0 ii( e. �//Ivy y[ G CITY/ZIP C L, C H EN I S , < C� �� 7 <br />CROSS STREET Gt1.W,IL�l_V-)jChe- P ^ VJY APN 0 3aa 00 s PARCEL SIZE Ll I LAND USE APPLICATION # <br />OWNER NAME ''[U1Y11 /n .14arwideI ilowen � ��C���� PHHO�NEErC&-q)7iyZ�006)0 <br />OWNER ADDRESS 21A-610 L' � I Z CITY/STATE/ZIP C i C: f L CNTS , C/� q3_22 7 <br />CONTRACTOR \1v 'oI r— PHONE <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CITY/STATE/ZIP <br />CITY/STATE/ZIP <br />PHONE <br />LICENSE ❑ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br />BILLING PARTY: JeOWNER I CONTRACTOR I SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) i- Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE )K 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 ❑ Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br /># of borings <br />^ New rump a rump rceplacemeni a rump Kepalr a Kalse vveu casing <br />WELL CONSTRUCTION <br />Drilling Method Cl Mud Rotary ❑ Air Rotary ❑ Auger _❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Dep 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 K Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib 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 V1FY <br />❑ Concrete Pedestal $IDimensions: Width _(# ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible ❑ Turbine ❑ Other HP 2— Pump Set ;p ft Standing Water Level <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 />MINIM M UR ADVANCE NOTICE REQUIRED FOR INSPECTIrON�S -PLEASE CALL (209) 953-7697 <br />SIGNED / TITLE DATE <br />DEPARTMENT USE ONLY <br />Application Accepted By -�� U` — Date /3 Area Employee ID# F <br />Grout Inspection By Date j El SPECIAL Well Permit <br />Pump Inspection By 11` 3 C_'2 I� C- 0(.. L Date 7 n � 39 / 21� ❑ WAIVER Received <br />Soil Boring Inspection By L Date Constructed Well Depth ft <br />COMMENTS mDeel tm I I W FUOi��BS+ <br />T <br />m <br />D <br />v <br />v <br />m <br />Cn <br />Cn <br />PE <br />Codes <br />SC Receive <br />Info A By I <br />Check#/ Amount <br />Gash Remitted <br />Da Permit/ Invoice # <br />Service Request # <br />Well ID# <br />�i3 <br />IS <br />i 21 <br />EHD 43-06 6/11/2019 4— V '9 v 6, !/ ✓ � / WELL /PUMP PERMIT <br />