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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />JOB ADDRESS <br />v 1 Y v VV ff./ V_/1 I -- 7 CITW%JA V V& L U r ) k U T ✓OC i <br />CROSS STREET <br />OWNER NAME <br />/I� r` <br />✓ JJ <br />/ <br />APN 'r�Oy,,I, OC 1 ' !D� PARCEL SIZE • i 4� LAND USE APPLICATION # <br />' , w` { � ✓` NE " ��OWNER <br />ADDRESSJ�,CITY/STATE/*PH <br />CONTRACTOR v_ <br />-�J '�"� <br />/ ♦ ✓vLn <br />CONTRACTOR ADDRESS <br />�P�/ON/E� �w <br />CtTYIST P U � "� — ` <br />SUBCONTRACTOR/CONSULTANT <br />_Py0 E <br />SUBCONTRACTOR/CONSULTANT ADDRESS 1 CCIIIT/�Y//SSTATE/ZIP(�I/�v/ <br />LICENSE C-57 %GC -61 D-09 Other • NUMBER X11 /6 - `-' EXPIRATION DATE q_?j '_ <br />BILLING PARTY: <br />OWNER <br />CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL.4pMPLING: <br />General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDE�Domesfic/Private <br />Imgation/Agricultural Industrial Water Quality Monitoring Coil Sampling/Characterization <br />Public Water System <br />If different from Owner <br />Water System Name Contact Name or Phone Number <br />TYPE OF WORK <br />New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) <br /># of wells Soil Boring(s) # of borings Geotechnical # of borings <br />Out-Of-ServW4V]0ell <br />Out -Of -Service Well Renewal Cross -Connection Repair <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 (94 Ib bag/5-10 gal water) Sand Cement sack mixt) gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL In tolled By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft L th ft T 'ck in Christy Box Stove Pipe <br />PUMP V Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT 1 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 />_N <br />g <br />0 <br />M <br />N <br />Application Accepted Byy� Date Area L Employee ID# <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By t Date WAIVER Received <br />Soil Boring Inspection B pDate p Constructed Well Depth ft <br />COMMENTS / /��' S In 11 Tr _ UV J , c o ra t� t� 16( Lt ic) ^, r <br />EHD 4346 6/11/2019 WELL fPUMP PERMIT <br />ANT <br />ED <br />2021 <br />O UNT y <br />MFIVT <br />