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1,"10►sio <br />f WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />rMUN-KEFUNDABLE PERMIT www.sjgov.org1encI EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS H -Ty l A♦rlklc ftyG ^ CrrY21P S�Ky, fftr °1520'7 <br />CROSS STREET VJ 1' kt &V, L^1AC APN IOq K3t0 t+ PARCEL SIZE 114 � LAND USE APPLICATION # <br />�_ LLt' _ <br />OWNER NAME 1 D I I r (!7 i II�� L I� f� PHONE <br />OWNER ADDRESS Nit <br />1 (. J J� �Q��'(� CITY/STATE/ZIP �rI �� Iol <br />^� �•� 1�: J (i�S/ .7✓ '`� 1, <br />CONTRACTOR Nitr 1 0 Q'Irsoa ' !I �IecMtO� �M��n•� 1 •�PHON/E 201t /"5 l ����1 <br />CONTRACTOR ADDRESS "'I J..n4WS"lV'%-'1 Qjp'j CITYISTATE21P �' j;' tf� �S2 I0 <br />SUBCONTRACTOR/CONSULTANT Skov � x'80 y E PHONE 56A- <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY//STATE/ZIP <br />A <br />LICENSE X C-57 ❑ C-61 D-09 -1 Other NUMBER � � 0 1 EXPIRATION DATE <br />BILLING PARTY: ❑ OWNER ❑ CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: _ General Mineral/Coliform Bacteria (4391) _i Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring X 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 X Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method i Mud Rotary r Air Rotary K Auger Cable Tool n Push Point Other <br />Proposed Well Depth167 ft Excavation — in diameter ❑ Open Bottom J 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 5 ft X Neat Cement (94 lb bag15-10 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 />CI Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in Christy Box I Stove Pipe <br />PUMP ❑ Submersible 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 />IIAINIMUM 4$ HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By ^/ L— Date i' pop' ) <br />Grout Inspection By Date <br />Pump Inspection By Date <br />/ 97C q' j� i 177 (� <br />Soil Boring Inspection By l j /( (\( Date S/ <br />—T, <br />COMMENTS <br />Area r` Employee ID# <br />LJ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />rn <br />m <br />D <br />v <br />v <br />m <br />N <br />PE <br />Codes <br />SC Received Chec <br />Info B as <br />Amount Date <br />Remitted <br />P@ImIV Invoice # Well ID# <br />Service Request # <br />jF5 <br />0 , Li2-+ <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />