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W VVI <br />n S-wvt ep <br />ftX-'L'/PKW p <br />wa <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAzELToN AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDME PERMIT <br />WWW.S <br />OV.Or /ehd <br />EX�PIIIRES 1 AR FROM DATE ISSUED <br />JOB ADDRESS ' <br />I/L <br />CITYrZj <br />�/ / G <br />CROSS STRE V <br />APPN <br />` Vr.� ' PARCEL SIZE 19,71—AND USF APP},�ATION #I <br />I /ir /� 1!/ '�^1 <br />OWNER NAME V` <br />I ` <br />PHONE ` <br />G1 Iu yI �' <br />OWNERADDRESS_ _ <br />1I VL I�'�/\ <br />(L. <br />CITY/STATE/LP <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />T <br />CONTRACTOR \� "J ✓ �/ <br />y�� <br />1 ► t <br />h <br />�, ` <br />HO O <br />CONTRACTOR ADDRESS <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />CITY <br />j <br />SUBCONTRACTOR/CONSULTANT <br />Bentonite (20% solids) Other <br />PHONE •" <br />SUBCONTRACTOR/CONSULTA�T ADDRESS <br />LICENSE C-57 C-61 0-09 <br />Other <br />CITY/STATE//—P <br />( <br />NUMBER V& <br />EXPIRAnoN DAT <br />BILLING PARTY: OWNER <br />ONTRACTOR <br />SUBCONTRACTOR/CONSULTANT <br />PUMP Submersible Turbine Other HP Pump Se It Standing Water Level ft <br />0 <br />m <br />m <br />Ls <br />S <br />DOMESTIC WE PuNG: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />. il <br />® ■.. <br />INTENDED USE Domesbc/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />!r,!ll�ll ' .iii►.�i� <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 />MonitoringWell(s) #of wells SoilBoring(s) #of borings Geotechnical #ofbonngs <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pum 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 Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (941b 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 />IFf <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Le ngt ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Se 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 />1� <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 48 HOUR ADVANZE;NOTICF RFOUIR F IN P TIONS -PLEASE CALL 20 -7697 <br />� <br />no ELI N NFA <br />/DEPARTMENT USE ONLY <br />Applicabon Accepted By Date y <br />Grout Inspection By Date <br />Pump Inspection By 10 Date <br />Soil Boring Inspection By Date <br />COMMENTS flew we W n0q'713 <br />Area Employee ID# A67 <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />[1 <br />EHD 4346 6111/2019 <br />WELL /PUMP PERMIT <br />. il <br />® ■.. <br />►_����VXA <br />!r,!ll�ll ' .iii►.�i� <br />EHD 4346 6111/2019 <br />WELL /PUMP PERMIT <br />