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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 85205 -6232 (208) 468-3420 <br />NON-REFUNDABLE PERMIT r'� ,/ d .S� OV.Or /ehd EXPIRES 'I YEAR FROM DATE ISSUED <br />JOB ADDRESS �yy,, +fir � � `�' � /�/l �l CITY/�ZjIP C <br />CROSS STREET j✓�V ���� J 1 APN ;J i � �1 '� 1 �' PARCEL SIZE L� ��� LAND USE A�P/PLICATION # <br />OWNER NAME /' •/J � �`��'` PHONE L �J � � �`�' j7 <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />v //� !/L /fit r <br />SUBCONTRACTOR/CONSULTANT �`� � ��L` <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE �C-57 ❑ C-61 ❑ D-09 ❑Other <br />BILLING PARTY: ❑OWNER ❑CONTRACTOR <br />CITY/STATE/ZIP <br />PH,�O�NE/�� � L/�� �( / !�! <br />CITY/STATE/ZIP �(I��y/�y�/r�lj/u{ • �% <br />PHONE L l 'S�����/ <br />CITY/S7TATE/ZIP_ <br />NUMBER � `7 / .� �yJ^ <br />❑ SUBCONTRACTOR/CONSULTANT <br />EXPIRATION DATE �~ �� <br />DOMESTIC WELL SAMPLING: f�General Mineral/Coliform Bacteria (4391)�Q Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: <br />TYPE OF WORK�NOW Well <br />❑ Monitoring <br />❑ Out-Of-Sei <br />C'r <br />WELL CONSTRUCTION <br />�2eplacement Well <br />(s) # of wells <br />Well <br />❑ Pump Replacement <br />Water System Name <br />Contact Name or Phone Number <br />❑ Well Alteration/Modification ❑Other <br />❑ 5oil Borings) # of borings ❑Geotechnical <br />❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ Pump Repair ❑Raise Well Casino <br /># of borings <br />Drilling Metho� Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other <br />Proposed Well Depth 3 ��� ft Excavation J'L 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 -C. � ❑Steel �PIBStIC ❑ Stainless Steel ❑Other <br />Grout Seal Depth /(jc> ft ❑Neat Cement (941b bag/5-10 gal water) and Cement�/�(i.� � sack mix/7 gal water <br />❑ Bentonite (20% sgliits) ❑Other <br />Grout Placement Method ❑ Pur>;I�d ❑Free Fall ❑Other ❑Retardant /Accelerator (name) <br />Installed By 'Driller ❑Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width Z_ ft Length ft Thick _ _ in ❑Christy Box ❑Stove <br />bmersible❑ Turbine ❑Other <br />HEREBY CERTIFY THAT 1 HA <br />JOAQUIN COUNTY ORDINANCE <br />CURRENT AND ACTIVE WITH l <br />WORKERS COMPENSATION LAV <br />MINIMUM 48 HOUR, <br />SIGNED <br />HP !.. Pump Set ft Standing Water Level ft <br />PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />ANCE NOTICE REQUIRED FORgINSPECTIONS -PLEASE CALL (209) 9+�53-/7697 <br />TITLE �/ (�/�+r+�' DATE � t%7' �"'O <br />n <br />DEPARTMEN�USE ONLY <br />Application Accepted By 1 Date � 'fi0'LO <br />Grout Inspection By ,(rcc.�L��L� �oc,.��:�. �v-,�. Date �1 ��®� 1.o'lA <br />Pump Inspecfion By 'C�r'�rit;+SlO CQta ,�. R� Date � � � `i-�ti� <br />Soil Boring I�nlspection By <br />COMMENTS /�r%ilicL.�� <br />Date <br />Area Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well <br />ft <br />m <br />D <br />0 <br />0 <br />m <br />w <br />EHD 43-06 6/11/2019 � � WELL /PUMP PERMIT <br />�� <br />'� � <br />�/.,til/ � <br />- � <br />����C� <br />� L� .. . �. <br />SIF <br />,' � <br />,► � <br />�l,/!�!�l�t��t�"c�� <br />� � � - , <br />EHD 43-06 6/11/2019 � � WELL /PUMP PERMIT <br />