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WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468.3420 <br /> NON-REFUNDABLE-PiERRMITT G www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE(ISSUED <br /> JOB ADDRESS (J�1 "'✓ J CO <br /> h ' d V 4-- CITY/ZIP a , y 1j__ `a Y7 y <br /> CROSS STREET �N `» Q t�I 0-O"O PARCEL SIZE ` <br /> YLAND USE� APPLICATION I D <br /> I S �I # >/' O <br /> OWNER NAME C.OA QA CL PHONE 1 6 "' p <br /> N <br /> OWNER ADDRESS S•VI k� CITY/STATE/ZIP ( Q <br /> CONTRACTOR \W 4- f l-'z' PHONE <br /> CONTRACTOR ADDRESS 3 6 6 ' V1) l 151�j CITYISTATE/ZIP V r 1 d C--. CCL• 1��a <br /> SUBCONTRACTOR/CON SULTANT N I» PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS C <br /> ITY/STATE/Z <br /> I <br /> P <br /> LICENSE V C-57 C-61 0-09 //Other _ NUMBER 15 �')l5 EXPIRATION DATE - <br /> BILLING PARTY: OWNER /CONTRACTOR SUBCONTRACTOWCONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE DomesticiPrivate Irrigation/Agricultural Industrial Water Quality Mcnitoring Soil Sampling/Characterization <br /> Public Water System <br /> If cifrerent from 0M Water System Name Conlan Name or Phone Number <br /> TYPE OF WORK Jew Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Wells) #of wells Soil Bonng(S) "or bonn5s Geolechn cal a of oonn9s <br /> .Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONS <br /> Drilling <br /> V"' <br /> Drilling Method 1//Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Wel( Depth 100 R Excavation t in diameter Open Bottom Gravel Pack/Gravel Size- # in dlameter <br /> Conductor Casing in diameter / Conductor Casing Depth —ft <br /> Well Casing Diameter ",d in Thickness/Gauge/ASTM Sched 5 rj, ;I� Steel k4eistk, Stainless Steel Other <br /> Grout Seal Dep a-00 it Neat Cement(94 1b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite( %solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant f Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Suomersible Turbine Other HP 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 /> WORKERS COMPENSATION LAWS. <br /> M11010yM 48 H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Aw a-r DATE 1- I yIA <br /> -a` <br /> F yMFNT <br /> CF�V�D <br /> 1A 9 ?�21 <br /> AQUA/C <br /> DN"OE gRTAI <br /> T <br /> DEPARTMENT USE PNLY / <br /> Application Accepted By __ Date 7 /�/ 1�1 Area �- Employee]D# (� <br /> Grout Inspection By Date Z. I SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date�—�-- Constructed Well Depth Ift <br /> COMMENTS r -) hoFCS l i r -0 <br /> PE Sc Racaived ChecW#/ Amount Permit] <br /> Codes Info Byn Cash Remitted ate Service Request# Invoice# Well IDA <br /> 310 J j <br /> '70 r <br /> EHD43-06 611,2019 <br /> WELL'PLIh!P PER1.11T <br />