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SAN JOADUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMWELL/PUMP PERMIT <br />ENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205.6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.s ov.or /ehd <br />i EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS t CrryfZjp <br />S-Izx-k�on /� <br />CROSS STREET "r P�rwa I^� U-, 7,jt'PARCEL $12E LAND USE PLICATION # <br />OWNER NAME5 PHONEOWNER AODRE55 TUA'PAN&.1 <br />Li nCITYISTATEIZJPCONTRACTOR /�� <br />PHONE 22 — q`3� • � <br />CONTRACTOR ADDRESS � � � GU <br />CITYISTATEOP 957-2 /S <br />SUBCONTRACTOR/CONSULTANT <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CITY/STATFOIn <br />LICENSE )C-57 C-61 D-09 _j Other/ n <br />NUMBER iL� EXPIRATION DATE <br />BILLING PARTY: _ OWNER <br />- CONTRACTOR -: SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING:..: General Mineral/COliform Bacteria (4391) - Dibromochloropropane (4392) _ Arsenic (4393) <br />INTENDED UsE DomeslidPnvate Ir gation/Agricultural - Industnal -Water Quality Monitoring Soil SamplinglChamctenzalion <br />Public Water System <br />If different from Owner Water System Name <br />Contact Nanta or Phone Number <br />TYPE 0 WORK - New Well Replacement Well Well Alteration/Modification <br />Other <br />Monitoring Well(s) # of wells Soil BOnng(s) $of borings <br />Out -Of -Service WellGeotechnical 7 oI borings <br />Out-OfService Well Renewal = Cross -Connection Repair <br />- New Pump k pump Replacement - Pump Repair <br />WELL (,ONSTRI :_ Raise Well C­tn., <br />Drllling Method Mud Rotary Air Rotary _ Auger Cable Tool Push Point <br />Proposed Well Depth fl Other <br />Excavation in diameter Open Bottom Gravel Pack/Gravel Size <br />Conductor Casing in diameter / Conductor Casing Depth ft in diameter <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad <br />Grout Seal De th - Steel _ Plastic -: Stainless Steel Other <br />Depth_, - Neal Cement (94 Ib bag/5-10 gal water) Sand Cement <br />Bentonite (20% solids) Other sack mixt) gal water <br />Grout Placement Method - Pumped Free Fall . Other <br />= Retardant /Accelerator (name) <br />PEDESTAL Installed By Griller =pump Contractor _ Other <br />Concrete Pedestal _;Dimensions: Width ft Lenqt 9 fl Thick in _Christy Box _Stove Pipe <br />P_MP"P {Submersible Turbine Other � <br />IHEREBY CERTIFY THAT I HAVE Pump Se( ft Standing Water Level It <br />WITH SN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS ED HAPPLICATIONIS AND THAT THE <br />AND RU ESAND REGULATIONS. NIOALSO ICERTIFYDOTHAT MYCR QUIREDELICENSEIS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE wlTla Al I <br />WORKERS COMPENSATION LAWS. <br />7 ��nrc i MCN I U E ONLY <br />Application Accepted By_ T� Date %Jl (,� C SPECIAL Well Permit ���QQQ ��/ <br />Area Employee ID#/ <br />Grout Inspection By Date - ���""' "�� <br />Pump Inspection By �� Dale <br />Soil Boring Inspection By WAIVER ReceivedDate <br />COMMENTS Constructed Well Depth ft <br />AYMENT <br />ECEIVED <br />JG 12 2021 <br />OAQUIN COUNTY <br />VIRONMENTAL <br />TH DEPARTMENT <br />WELL i UI;.P PEP,;.ni <br />