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I N <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />IVUIy-MLt,UNUAtJILL rLHmiI c` WWW.S1gov.org/ena �^�l=Xl'lKI=b 9 YEAR FROM DATE ISSUED <br />&k <br />JOB ADDRESS 150 a �.'�, C% - CITY/ZIP _ 5I \�('�C,(� `IS )Qs <br />CROSS STREET APN t 55 I qua t PARCEL SIZE (�' LAND USE APPLICATION # <br />OWNER NAME J\l. 14AM PHONE r� r <br />OWNER ADDRESS .�7��,��LInC(�1M1 ,I_ CITY/STATE/ZIP_ �Ci1L'�TN1 C`52W <br />CONTRACTOR e--3 Ppow� _pf'j L PHONE �P,3-10,o-7-546V <br />CONTRACTOR ADDRESS 1 G I� J�(, �/� �� / j �/ CITY/STATE/ZIP I I UyjA 12 cj, o(5, a y <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS _ <br />LICENSE ❑ C-57 W/C-61 ❑ 0-09 <br />BILLING PARTY: ❑ OWNER <br />❑Other <br />61/CONTRACTOR <br />PHONE <br />hCITY/ST�ATE/Z/IP_ <br />NUMBER "127 1ya Ll' EXPIRATION DATE <br />❑ SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: L7 General Mineral/Coliform Bacteria (4391) ❑ 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: Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well ❑ Replacement Well ❑ Well Alteration/Modification 0 Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />New Pump ❑ Pump Replacement ❑ 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 _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 Ib bag/5-90 gal water) ❑ Sand Cement sack mix17 gal water <br />❑ Bentonite (201% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Ir stalled By CI Driller q Pump Contractor ,/ [I Other TM Concrete Pedestal ❑Dimensions: Width Or fA Length r ft Thick Ljj= in ❑ Christy Box ❑ Stove Pipe <br />PUMP •{t Submersible Cl Turbine ❑ Other HP SCS Pump Set 1 1�7 ft Standing Water Level Uh I ,,L 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 />TMI 48 HOUR ADVANCE NOTICE REQUIRED PO INSPECTI NS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE `(� /t%` DATE L°T <br />1-1 <br />t 1810EHazelWA. <br />DEP R MENT USE ONLY <br />Application Accepted By Date <br />i <br />Grout Inspection By Date <br />Pump Inspection By ate A T1 <br />Soil Boring Inspection By Date <br />COMMENTS <br />�A <br />rn <br />H <br />D <br />0 <br />0 <br />m <br />m <br />w <br />N <br />Area ( C() <br />"Employee ID# ` �J <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />PE SC Received Amount <br />Codes Info Cash Remitted <br />Date Permit! Invoice # Well ID# <br />Service Request # <br />EHD 43-06 6/11/2019��1 rury�; ; zj WELL /PUMP PERMIT <br />wt� 9,'1 C- I <br />