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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 />JOB ADDRESS ,\ T -4'T W J �Lk o\-O'nc _ CITYRIP Sk0Cx-4apn . CV- <br />CROSS STREET' v QP11" eQj t�APN /:Zj � 1.. �56PARCEL SIZE LAND USE APPLICATION 0 <br />T <br />OWNER NAME J \YY1 \�? Y �.t \)o Z.J. Ca c-- q CPHONE �(O ✓ f' 3 <br />OWNER ADDRESS 5S5 \TtCC _ ic,\\ CITVISTATEILP cl,y-f 011"1 �'O �Cl't Q5S't.j <br />CONTRACTOR �� S jay N\\\Y\A PHONE ZO <br />/ <br />CONTRACTOR ADDRESS C a( -A ` l�) (` CITYISTATE21P IC4 p1G/ \ <br />SUBCONTRACTORICONSULTANT M\r� YD.C�\�\L 'CY`��(\�Y\GC.Vi�t�r`C\ '1` PHONE 'Al, IA <br />IO Lei.l ' <br />SUBCONTRACTOR/CONSULTANT ADDRESS 4�V�A`OLIYGGUF-r0 lJ�r \\1C CCIITYYISTATE01- W • .JGL`( QY't1A�l�`[7 LCA / c\S�CiUS <br />LICENSE AC -57 C C-61 ❑ D-09 D Other NUMBER i JM ;C1 t10 EXPIRATION DATE <br />BILLING PARTY: ❑ OWNER 0 CONTRACTOR rf� SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: D General Mineral/Coliform Bacteria (4391) 17 Dibromochloropropane (4392) D Arsenic (4393) <br />INTENDED USE D Domestle/Prtvate C Irrigation/Agricultural D Industrial ❑ Water Quality Monitoring C Soil Sampling/Characterizatlon <br />❑ Public Water System <br />Ifdifferent from Owner. Water System Name Contact Name mPhone Number <br />TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification ❑ Other <br />0 Monitoring Well(s) III of wells ❑ Soil Boring(s) Nofborings 0 Geotechnical Nof borings <br />❑ Out -Of -Service Well C Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />0 New Puma 0 Puma Realacement 0 Puma Reoair 0 Raise Well Casina <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary D Air Rotary 0 Auger r] Cable Tool 0 Push Point ❑ Other <br />Proposed Well Depth ft Excavation 16 tt - In diameter ❑ Open Bottom 0 Gravel Pack/Gravel Size In diameter <br />0 Conductor Casing In diameter I Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel 0 Plastic C Stainless Steel ❑ Other <br />Grout Seal Depth _ft ❑ Neat Cement (941b bag/S-10 gal water) ❑ Sand Cement sack mind7 gal water <br />0 Bentonite (20% solids) 0 Other <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor ❑ Other <br />0 Concrete Pedestal ❑Dimensions: Width _ ft Lente ft Thick in ❑ Christy Box 0 Stove Pipe <br />(PUMP 0 Submersible0 Turbine ❑ Other HP PumpSel It 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 0MPENSATION LAWS. <br />48 �RIADVA� N�Jj ICE REQUIRED FOUR INSPECTIONS - PLEASE CALL (209) 953-769j7 <br />) ,�,IL� TITLE rl\1\St�C \�`�Y1[i DATE 1130 / IA1 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By _ <br />COMMENTS _ <br />J <br />/0.EPARTMENT�/ E ONLY <br />. __ Date �j,/1�, <br />Date 7 <br />Date <br />Date <br />Y <br />4�4f4yT <br />a c <br />Tye p jEH" �'V7Y <br />'9R <br />AreaEmployeelD# <br />0 #SP,.,❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />EHD43-06 611112019 WELL /PUMP PERMIT <br />