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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 />r1IV19-Rtl-UNUAtILt 1"1=11Mll <br />SC Received <br />Info B <br />rAYIKtJ 7 TLAM t-KUM U[A-I t1155UED <br />JOB ADDRESS I U0 (� <br />�,j n !--�-�I7\ <br />`_ 1 ' pw(ww.5jgov.0rgfe,/n0 <br />w } �X L c i <br />• t (, cITYI]ZJP S -V c. (. V � c �n <br />CROSS STREET e VIA Mcg <br />11, K <br />/�l-C <br />y APN l / J� O Cl <br />PARCEL SIZE c, 5 r G LAND USE APPLICATION # <br />^ <br />OWNER NAME JLC_$ i r <br />S 0 1 11 <br />1VlUt17 <br />F6) x'41 I Tll 9 I r <br />! �> <br />PHONE JC ri ,� ZI - �%� 0, <br />OWNER AODREE P� TJX <br />iH�� <br />L-r,cl> `�SLuI <br />-ITY/STATE/ZJP t --C l a 1 C Gs y I— <br />CONTRACTOR V �� 11' <br />i f . 11 ` n `1 <br />PHONE ? Ci -7 - / 7 9 <br />CONTRACTOR ADDRESS C- <br />t�L <br />'-/ !1 %� <br />{ <br />/ <br />CITY/STATE/LP Crl1 I . A 5 C, 3 <br />TANT <br />TANT ADDRESS <br />LICENSE 7CC-57 - C-61 D D-09 <br />BILLING PARTY: ❑ OWNER <br />CITYY�ISTAATEZP_ <br />Other NUMBER L9`IZ13SL <br />(CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />PHONE <br />EXPIRATION DATE 7-3 I - �? R <br />DOMESTIC WELL SAMPLING: I I General Mineral/Coliform Bacteria (4391) [ Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private YInigation/Agricultural ❑ Industrial D Water Quality Monitoring 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 i i Well Alteration/Modification I i Other <br />1 Monitoring Well(s) # of wells I I Soil Bonng(s) # of borings I Geotechnical # of borings <br />Out -Of -Service Well 1I Out -Of -Service Well Renewal I -I Cross -Connection Repair <br />Drilling Methodx Mud Rotary ❑ Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth 4UQ It Excavation 14 in diameter Open Bottom Gravel Pack/Gravel Size V-4 _ in diameter <br />Conductor Casing in diameter / r Cond'uc1to�r�`Casing Depth ft <br />Well Casing Diameter � in Thickness/Gauge/ASTM Schede Steel (Plastic Stainless Steel Other <br />Grout Seal Depth CI C., ft Neat Cement (94 Ib bagl5-10 gal water) }% Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) C Other <br />Grout Placement Methnod"A Pumped LI Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller CI Pump Contractor I Other <br />oncrete Pedestal I 'Dimensions: Width 4 it Length ft Thick __�-� in I I Christy Box ! I Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set i75 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 COMPENSATION LAWS. <br />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7-697 <br />SIGNED 7 <br />�To"'%/� TITLE' ��L- CS ,C� Prl DATE '� ! 2-L- <br />0, N") -c <br />Application Accepted By _ <br />Grout Inspection By 4 <br />Pump Inspection By _ <br />Area ..) t' C. Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS il/ III E <br />A <br />D <br />M <br />w <br />PE <br />Codes <br />SC Received <br />Info B <br />hec Amount Permit/ Well ID# <br />Invoice # <br />Caah Remitted Date Service Re uest # <br />l <br />vl S� <br />01) <br />EHD 43-06 6/112019 WELL/PUMP PERMIT <br />