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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 />NON-REFUNDABLE <br />PERMITT wWw.s- ov.or iertd EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADDRESS y// r,� O rtes + p I In <br />le C- 'P $� c.c,Tn &/ 9 5 207 <br />CROSSSTREEiMIGyQE(/1/J((� DQAPN 11 c�G_ %y PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME C T'Y O F S -I -q f..�K. T`C� l�J —'JL— (Zt^9 q37— ZI Z Y, <br />L PHONE <br />OWNER ADORFss ! Z S /V �- f� 0 O O �j J Cm/STATE2iP S 7� G l — 7 , J C A `15 G'4 <br />CONTRACTOR T" I C. (Z-) L -L. I o -J (r / W G PMONE (SS IJ) Z%/; — C%077 <br />CONTRACTOR ADDRESS G 336111 G!�/'�J a' 10 A �'S-T - CRY/STATTJZJP ..—S� O�L.� G:2 . l.f�,'14 ' ZI Z 6 <br />SUBCONTRACTOR/CONSULTANT / ) P 1❑❑tjV 6 � QT' � R -I Z- SLI,o "J 5"C""' / E (/ 16) -5 <br />'SUBCONTRACTO`RICONSULTAM ADDRESS V3 % �,1 V+�QE� 7%OL.£ ir;;ISTATEIZIP M%LL.s {/'/LLE �J� Zf�CC <br />LICENSE -.1 -$? C C-61 0-09 Other. NUMBER 5177- EXPIRATION DATE /T3a Z -c z <br />BILLING PARTY: C OWNER C CONTRACTOR C SUSCONTRAGTOR/CONSULTAMT <br />DOMESTIC WELL SAMPLING: 0 General MinerBUColiform Bacteria (4391) C Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE 3 Domestic/Private n InigatiorVAgricuoufal C Industrial ❑ Water QualityMonitoring 7 Soil Sampling/Charaderb tion <br />Public Water System <br />If different from C—.' Water yslem me a cele or umbar <br />TYPE OF WORK New Well 1, Replacement Well i Well AtteratioruModl6cation I.YOlher _G ATW O 0 1 C j .-r- i -CG7'j 0!,-s <br />Monitoring Well(s) # of wells r Soil Boring(s) L or wdrga n Geotechnical a of bongs <br />J Out -Of -Service Well L Out -Or -Service Well Renewal U Cross -Connection Repair <br />J New Pump -1 Pump Replacement G Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION� <br />Drilling Method ;;v ud Rotary I Air Rotary ❑ Auger D Cable Tool ] Push Point r Other <br />Proposed Well Depth q 5 it Excavation 12— In diameter C Open Bottom C Gravel Pack/Gravel Size in diameter <br />a Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ In Thlokness/Geuge/ASTM Schad F Steel C plastic D StzMaas Steel Fi Other <br />Grout Seal Depth_-ZQ ft ❑ Neat Cement (941b bag/5-10 gat water) C-16and Cement, ' 0�3sack mix17 gel water <br />Bentonite (20% solids) 7 Other .ir <br />Grout Placement Method-4umped -1 Free Fall Other -1 Retardant / Accelerator (name) <br />PEDESTAL Installed By C Driller E Pump Contractor ❑ Other <br />Concrete Pedestal LJDimenslons: Width It Length ft Thick In F Christy Box ❑ Stove Pipe <br />PUMP =' SubmersibleC Turbine .; Other HP Pump Set R Standing Water Level h <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 />4 NIM"U�M48�HOUR /��yr✓���'/A(�NCE NOTICE REQUIRED FOR QIINtSP�1ECCTIIONS - PLEASE C;Ai-L IZU9) 955�J-769, <br />SIGNED �,t/4t.�— V �% "— TE <br />T11 OP"'A" � S 1XAW,# 6'rA f <br />DEPARTMENT USE ONLY I <br />Application Accepted By L— %/! o�� Arse ;j $tJLK4Jh / r Employee IDN /y/ <br />5 <br />Grout Inspection By Date r 7i 0 SPECIAL We11 Permit <br />Pump Inspection By Date C WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />EMD 048 6111/2019 <br />f - I <br />9 yM <br />CFj�NT <br />EO <br />o ?02, <br />T <br />y <br />