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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 96205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMITWWW.S <br />Ov.or 1ehd <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />C' <br />CITYidP <br />CROSS STREET <br />OWNER NAME <br />APN � y 70 'Q I PARCEL SIZE LAND USE APPLICATION #A <br />G <br />PHONE 2� 1 <br />OWNER ADDRESS <br />, f <br />C"l ,� <br />C <br />A CITY/STATEIAP � <br />/'' a � C� �7 <br />]��r C i ! 52)6 <br />CONTRACTOR <br />OO <br />1 <br />YIC <br />PHONE 2 -0'::1 - <br />0'::1 -CONTRACTOR <br />CONTRACTOR ADDRESS <br />�' U <br />Vim/ l� <br />VX �� CITY/STATE21P S <br />1 111 �� <br />SUBCONTRACTOR/CONSULTANT <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE t -C-57 <br />0 C-61 <br />0 D-09 <br />(CITY/STATE/2JP <br />D Other NUMBER I l% _ <br />EXPIRATION DATE <br />BILLING PARTY: <br />D OWNER <br />CONTRACTOR G SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE 0 Domestic/Private ❑ Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK 0 New Well D Replacement Well 0 Well Alteration/Modification 0 Other <br />C Monitoring Well(s) # of wells 0 Soil Boring(s) a of borings 0 Geotechnical # of borings <br />0 Out -Of -Service Well 0 Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />0 New Pumo A Pumo Replacement 0 Pumo Repair 0 Raise Well Casing <br />Drilling Method 0 Mud Rotary 0 Air Rotary ❑ Auger 0 Cable Tool 0 Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom G Gravel Pack/Gravel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad C Steel C Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth ft 0 Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br />C Bentonite (20% solids) 0 Other <br />Grout Placement Method D Pumped 0 Free Fall ❑ Other G Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller 0 Pump Contractor C Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in 0 Christy Box C Stove Pipe <br />PUMP X Submersible❑ Turbine 0 Other HP I _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 />P,KIRTMENT USE �O,N(LY <br />Application Accepted By Date <br />GroutInspection By to <br />Pump Inspection By I ` Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />ft yMFNr <br />CE�V�eD <br />SqN ✓ ? 202j <br />FNV�gQU�N <br />N1 -k rN P,gR ry <br />NT <br />Area Employee ID#v. 14 <br />PECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />EH043-M 6111/2019 WELL /PUMP PERMIT <br />