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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 PERMIT www.sjgov.org/ehd E CPIRE 1 YE R FROM DATE ISSUED <br />JOB ADDRESS y e _=_ CITY/ZIP <br />CROSSSTREET_ A- �i--APN �,�� PARCEL SIZE 3. 0S LAND USE <br />APPLICATION# <br />OWNER NAME AA /✓ Q L,-,/& <br />_ �I �-(��-j.{-� PONE r_ <br />OWNER ADDRES—S-J ` ✓V W �/-•�/j [TAIE/LIW11.5 _ <br />CONTRACTOR .S�_�t--�' 1 �+/ l L PH E �O� <br />V ` ITY/ <br />CONTRACTOR ADDRESS v `A T I� � ` U <br />SUBCONTRACTOR/CONSULTANT Pry^} <br />IV <br />SUBCONTRACTOR/CONSUL TADDRESS CITY//JSTATEIZZIP <br />LICENSE C-57 C-61 D-09 /her X•r NUM "' WPO EXPIRATION DA �/ 0 <br />BILLING PARTY: OWNER ,V /CONTRACTOR SUBCONTRACTORICONSULTANT <br />)OMESTIC WELL !ePILING: 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 Scnng(s) — n of borings Geotechnical p of borings <br />Out -Of -Service VII Out -Of -Service Well Renewal Cross -Connection Repair <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 (941b bagl5-10 gal wafer) Sand Cement Sack mix17 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name)— — <br />�n <br />N <br />l` <br />Im <br />PEDESTAL Installed By Unller !Jump contractor Other <br />Concrete Pedestal Dimensions: Width ftLent ft Thick in Christy Box St v Pi <br />PUMP Submersible Turbine Other HP _ Pump Set ft Standing Water Levelft (� 1 <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. t f1 <br />DEPARTMENT USE ONLY <br />Application Accepted By Date lam— <br />Area e Employee ID# <br />1 <br />_ <br />Grout Inspection By <br />_ -- <br />Date _ _ <br />SPECIAL Wel! Permit <br />Pump Inspection By i d � Osalt <br />�.. _ Date Vr(I <br />WAIVER Received <br />Soil Boring Inspection By <br />Date <br />Constructed Well Depth <br />- --- <br />COMMENTS <br />PE <br />I SCReceived necld <br />Amount Permit/ <br />Pate <br />Invoice # <br />Codes <br />Info Remitted <br />Service Re uast <br />3 <br />_ _ <br />os0Z <br />_ <br />R <br />D <br />— -- - <br />- --- <br />--- <br />EMD 4306 6/11/2019 <br />WELL !PUMP PERMIT <br />N <br />O <br />T CNS- <br />T44r <br />