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N <br />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 />SC <br />Info <br />www.sjgov.or9iena <br />LAI IKtb 9 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />q3 $0 <br />CITY/ZIP` <br />�F1�L <br />� 77 oa 1 <br />Ll (. <br />CROSS STREET L <br />_,PN PARCEL SIZE Is <br />LAND USE APPLICATION # <br />OWNER NAME , <br />/r <br />PHONE ���02 J9 <br />i�' <br />L139a <br />OWNER ADDRESS _ 3 A / -^ <br />t <br />CITY/STATE/ZIP <br />CONTRACTOR ) <br />y / <br />j (�(d �'�.. <br />(_ � <br />+�J3 7 — L f �✓ <br />PHONE <br />�7" 1 <br />7 <br />/ <br />CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />el,~ Vz- <br />SUBCONTRACTOR/CONSULTANT <br />_ 6 <br />1_L�.►� <br />PHONE <br />NSULTANT ADDRESS <br />LICENSE 1;K-57 ❑ C-61 ❑ D-09 ❑ Other <br />BILLING PARTY: ❑ OWNER ❑ CONTRACTOR <br />CITY/STATE/ZIP <br />NUMBER / (V EXPIRATION DATE 2.3 <br />❑ SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: XI General Mineral/Coliform Bacteria (4391)' Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE omestic/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 ,illew Well ❑ Replacement Well <br />❑ Monitoring Well(s) # of wells <br />❑ Out -Of -Service Well <br />Pum <br />❑ Well Alteration/Modification ❑ Other <br />❑ Soil Boring(s) # of borings ❑ Geotechnical <br />❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ Raise Well Casino <br /># of borings <br />Drilling MethodAtMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth2EF0 ft Excavation 12— in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter,6 in Thickness/Gauge/ASTM Sched')—W ❑ Steel Plastic ❑ StainlessSteel ❑ Other <br />Grout Seal Depth 11370 ft ❑ Neat Cement (94 Ib bag/5-10 gal water) Sand Cement L 0 • 2 sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method dumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By 90riller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width V ft Length OF ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP ubmersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level 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 />SIGNED <br />DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />'-I <br />erg. TITLE (/ Wj'l��'L DATE <br />DEPARTMENT USE ONLY <br />Application Accepted By `-� Date $' S o?oa b Area y ��� > YA#e DA <br />Grout Inspection By �1`wn4,C Lo lYtrN,� 1%K. Date �I_t2y2c SPECIAL*ECVN 7.� <br />� <br />Pump Inspection By c+�. c(A �C/t+fig f t Date 17j2712VZ1 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depi°fiU 2 5 202n_ft <br />COMMENTS SAN,Ingr,, <br />�E-N-,VITRO L,T„Nn' <br />T <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Chec Amount Date Permit/ Invoice # <br />Cash Remitted Service Request # <br />ell ID# <br />q3 $0 <br />0,5-1 <br />isa 20 <br />Ll (. <br />JR0 <br />yao l.0 U <br />y3a IIsm <br />tl t1 <br />L139a <br />70 Ic it ti <br />EHD 43-06 6/11/2019 ., WELL /PUMP PERMIT <br />