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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 />r Www.S Ov.oC Lena r_AI`1KCJ "I YEAR FROM DATE ISSUED <br />JOB ADDRESS l 57') (� `O /n L CITY/ZIIPP, G <br />CROSS STREET 75-6Z <br />��y��I<< %�'/ � >> APN L/�� Z� ��S PARCEL SIZE / ' LAND USE APPLICATION # y� <br />OWNER NAME '6 exl k6- <,74x< -'A PHONE !�' 3? O - �q S-? _ 7y� � <br />OWNER ADDRESS r l A4 I <br />CITY/STATE/ZIP <br />CONTRACTOR �'�� 4/`Ct!ILL PHONE J 7 7�►J� <br />CONTRACTOR ADDRESS PD CITY/STATE/ZIP <br />SUBCONTRACTOR/CONSULTANT A6 PHONE. <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE ,;Z-57 ❑ C-61 ❑ D-09 ❑ Other <br />CITY/STATE/ZIP <br />' S EL) <br />NUMBER ��%l.ia? XPIRATION DATE <br />BILLING PARTY: ❑ OWNER ❑ CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING:,X General Mineral/Coliform Bacteria (4391)4W 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 />Tl'PE OF WORK *" Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other h r <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) #of borings ❑Geotechnical IF&ME1i <br />ph <br />11 Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />A<New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing SE[� Ir <br />0 4 pqn <br />WELL CONSTRUCTION gAIV JOA F f_U <br />Drilling Method,>eMud Rotary Ll Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other F QUIN C <br />Proposed Well Depth3 ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size TNOEPeN},eter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft MENT <br />Well Casing Diameter A16— in Thickness/Gauge/ASTM Sched ❑ Steel Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth Zap ft ❑ Neat Cement (94 lb bag/5-10 gal water) >r8and Cement ZOO � � sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method,s44Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width �ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP eSubmersible❑ 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 />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED � _A'4_1 TITLE 67WA e- DATE / 9 - L L', <br />U L Y A K I IVI t N I U J t V N L T <br />Application Accepted By Li li Date 9 y a0ab <br />Grout Inspection By A -!.l IyNm Date al alun <br />Pump Inspection By �w�c'E,\e �•. ��Date1- <br />Soil Boring Inspection By 1Date <br />COMMENTS (�trr>�k-�i�r,1 100 ci210 `11i�12s�2 A1ZScJ u1 <br />Area q , c , Employee ID# DA <br />❑ SPECIAL Well Permit <br />] WAIVER Received <br />ConFtructed Well Depth -; `J7� ft <br />=IB <br />T <br />m <br />m <br />D <br />v <br />0 <br />m <br />m <br />N <br />N <br />PE SC <br />Codes Info <br />ReceivedCheck# <br />Cas <br />Amount Dae <br />Remitted <br />Permit/ Invoice # <br />Service Re uest # <br />Well ID# <br />4390 Os 1 <br />Z <br />4 ►sa z0 <br />WP <br />434W6 186 <br />vie boLlIM <br />4391 <br /># /so <br />We 09LIII 4 <br />H39d <br />Or Wit 40 <br />EHD 43-06 6/11/2019 V WELL /PUMP PERMIT <br />