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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 />JOB ADDRESS <br />CROSS STREET C <br />OWNER NAME <br />C� <br />OWNER ADDRESS C� <br />www.sjgov.orglend EXPIRES 1 YEAR <br />XPIRES1YEARR FROM DATE ISSUED <br />CITY/ZIP <br />PARCEL SIZE 3• �cl LAND USE APPLICATION # /gy <br />PHONI�2'" / '32 7--5A 7p/ <br />CONTRACTOR ��`�L� �/" ` � /i(// � L/L�J��� �/S cPHONE <br />�� <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />SUBCONTRACTOR/CONSULTANT ��� PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CIT <br />Y/STATE/ZIP / <br />LICENSE ;VC -57 �OC-61 ❑ D-09 ❑ Other \ NUMBER !4' rl EXPIRATION DATE C <br />BILLING PARTY: ❑ OWNER ❑ CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />NTENDED USE eV 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 # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump 4 <br />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 11Steel 11Plastic ❑ 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 <br />❑ Concrete Pedestal [I Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />44 <br />PUMP Submersible❑ Turbine ❑Other HP 2 Pump Set ft Standing Water Level ft <br />I HEREBY CE TIFY 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 />MINI 4$ O ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-769 <br />SIGNED '/��r�% �j�%2 — TITLE 1L2� DATE <br />DEPARTMENT USE ONLY <br />Application Accepted By C/L Date 7 IO <br />Grout Inspection By (/���n Date <br />Pump Inspection By ww: S to lS�/c'h 7� Date 12 Z <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area 9 1 (� I Employee ID# F9 <br />SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />W <br />m <br />0 <br />0 <br />0 <br />m <br />PE <br />Codes <br />SC Received Check#/ <br />Info B ash I <br />Amount Date <br />Remitted <br />Permit/ Invoice # Well ID# <br />Service Re uest # <br />Lia <br />v S-0 <br />7 0 <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />