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WELL/PUMP PERMIT <br /> SAH JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS n CrrY////Z���IP <br /> 11` D <br /> CROSS STREET APN {^� ARCEL SIZE LANE)USE APPLICATION# p <br /> OWNER NAME WN ��`bbl/8W m <br /> p <br /> C� PHONE�` <br /> OERADDRESS VO CITY/STATEZP <br /> CONTRACTOR IVKI r PHONE r <br /> CONTRACTOR ADDRESS CITYISTATEMP 7 7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS C /STATEIZIP nJ <br /> LICENSE C-57 ❑C-61 O D-09 C Other Qt R'I�ZZ EXPIRATION D <br /> NUMBER� ATE� D-i—� <br /> DOMESTIC ELL SAMPLING:0 General MinerallColiform Bacteria(4391)D Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE �omestic/Private D Inigation./Agricultural ❑Industrial ❑Water Quality Monitoring 0 Soil Sampling/Characterization <br /> ❑ ublic Water System <br /> If Qdferent from Owner Water System Name Contact Name or Phone Numoa! <br /> TYPE OF WORK G New Well Replacement Well E1 Well Alteration/Modification ❑Other <br /> Ll Monitoring Wel s #of wells ❑Soil Boring(s) sof bonne, D Geotechnical r of b0finfl° <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal E.Cross-Connection Repair <br /> ❑New Pump O PUMP Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method j.,hMd Rota D Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth"2 It Excavation��in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Cond��o Vsing Depth it <br /> Well Casing Diameter. in. Thickness/Gauge/ASTM Schad ❑Steel Plastic ❑Stainless Steel it Other <br /> Grout Seal Depth it ❑Neat Cement(94 Ib bag/5-10 gal wa <br /> ter)toniter) Sand Cement sack mixR gal water <br /> t/�Bentoni a 20%solids) ❑Other <br /> Grout Placement Method Pumped ❑Free Fail 0 Other ❑Retardant/Accelerator(name) <br /> FEKE)ESTA& Installed By U Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dtmenslons:Width It Length ft Thick in �j Christy Box 0 Stove Pipe <br /> PUMP ❑Submersible❑Turbine ❑Other HP Pump Sel 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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPE T PLEASE CALL(209M53-7697 <br /> SIGNED TITLE 1 DATE 06 <br /> kill III k —ti <br /> �,,(02, <br /> P YMENT <br /> RECEIVED <br /> AU 2 3 2021 <br /> I1 JOAQUINCOl1NTY <br /> NVIRONMENTAL <br /> uC L111 OLPARTMLNI <br /> DEPARTMENT USE .ONLY <br /> Application Accepted By �/ - Date��✓� tJ/ Area I� � ) Employee ID# AGS <br /> Grout Inspection By / Date 1I ( c l--) 1 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS ,,-1 Well me. r S J,it r7717/, <br /> PE SC Received Check#/ AmountDate Permit/ Invoice# Well IDS <br /> Codes Info I ey j Cash Remitted rvi R oast <br /> 310 U c) <br /> 3rt1 i f <br /> EHD X106 (i/at/1a ALL(PUMP PERMIT <br />