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r WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1666 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 466-3420 <br />(� NON -REFUND PER�MIITT .S* OV.Or lehd EXPI ES 1 YE (FROM DATE ISSUED <br />I <br />JOB ADDRESS W CIN P `^ (M <br />I ` I <br />1-f 15 <br />CROSS STREET E. APN a a 73 6 o 1 a73 6 o 1 a PARCEL SIZE 47 LAND US /PLICATION # <br />OWNER N���/� rj I II PHONE -�(3�-- <br />CONTRACTOR / / r/L PHONELO-2 U <br />CONTRACTOR ADDRESS v l12 A CITY/STATEIZIP <br />SUBCONTRACTOR/CONSULTANTP�HON <br />SUBCONTRACTORICONSULT DRESS 1A // <br />Cr YISTATEIZIP � V % <br />LICENSE C-57 C-61 D-09 Other Z, NuM V EXPIRATION DATE_ 3 <br />BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTORICONSULTANT <br />DOMESTIC WE vPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />IYtiifferent from O—er Water System Name Contact Name or Phone Number <br />U P <br />TYPE OF WORK V New Well Replacement Well Well Alteration/Modification Other <br />C� <br />1 •N} G <br />///��� bt Monitoring Well(s) # of wells Soil Borings) #of borings Geotechnical #of borings <br />',) Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />J1_ <br />i New Pump Pump Replacement Pump Repair Raise Well Casing <br />WWW <br />WELL CONSTRUCTION <br />Date <br />Date <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 />Date <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />It <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />lI �A GJ ���0 ^ CO'D� <br />Grout Seal Depth ft Neat Cement (94 lb 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 />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Leith It Thick in Christy Box Stove Pipe <br />\ <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 />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FO I SPECTIO S,y-,yP^LF,f MCALL (209)153 �9 <br />SIGNED TITLE /' Y('yDATE (� <br />_H <br />A <br />9 <br />M <br />w <br />T <br />2) <br />ANT <br />l vpn <br />13 2021 <br />IN im:wmgm�r <br />/fes/' DEPARTMENT/FUSE ONLY <br />`— <br />*SP211-W111 <br />RNV1Rp M','0UApplication <br />pMENTq�ryGrout <br />Accepted By <br />vDateArea� <br />EmployeelD#�`TH <br />Permit gRTMFNT <br />Inspection By <br />Pump Inspection By <br />Date <br />Date <br />WAIVER Received <br />Soil Boring InspecticrBy <br />Date <br />Constructed Well Depth <br />It <br />COMMENTS well pert' <br />lI �A GJ ���0 ^ CO'D� <br />V`N �G <br />IN im:wmgm�r <br />® . <br />�r•II1►l/.�./J�i_C7L'TrjIIE��r'1 <br />[►.�1��11jiL�'a�!.� <br />EHD 43-06 6/1 t/2019^ 1�, ti _ , �j5 -1m � 2 <br />/ /J/ `y /f. e* / WELL /PUMP PERMIT <br />