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WELL/PUMP PERMIT <br /> a SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT WWW.S]gov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> IRtJOB ADDRESS Ye CITY/ZIP 1 m <br /> CROSS STREETrlu) N ARCEL SIZE1LAN/^D1USE APPLICATION# <br /> OWNER NAMEM PHONE 2Zq3t�, D mDo <br /> w <br /> OWNER ADDRESS CrTY/STATE/ZIP it C °I <br /> CONTRACTOR '�.�.- PHONE `t C; <br /> CONTRACTOR ADDRESS CITVISTATE/ZIP,t ,t'ACS-)r0 0 C K 9 53s <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP 1 <br /> LICENSE -57 C-61 D-09 Other NUMBER 2-9'08 13 EXPIRATION DATE _13 <br /> BILLING PARTY: OWNER NTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELLS PLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)El Arsenic(4393) <br /> INTENDED USE omestic/Privale Irrigation/Agricultural Industrial Water Quality Monitoring i Soil Sampling/Characterization <br /> C Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK L New Well 11-11 eplacement Well D Well Alteration/Modification L Other <br /> L Monitoring Well(s) #of wells D Soil Boring(s) #of borings Geotechnical #of borings <br /> L Out-Of-Service Well D Out-Of-Service Well Renewal [i Cross-Connection Repair <br /> New Pump C Pump Replacement D Pump Repair i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodLid Rotary -i Air Rotary Auger Cable Toot Push Point Other <br /> Proposed Well /Depth�_ft Excavation _in diameter Open Bottom ravel Pack/Gravel Size.No in diameter <br /> Conductor asing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM SchedShILZI L Steel antic Stainless Steel Other <br /> Grout Seal Dth2 IlD Qft Neat Cement(94 lb bagl5-10 gal water) Sand Cement sack mix/7 gal water <br /> $ Bentorytey(20%solids) Other <br /> Grout Placement Method Limped Free Fall i Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Xump Contractor Other <br /> Concrete Pedestal Dimensions:Width It Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible❑Turbine Other HP Pump Set It 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 /> INIMUM 48 HOUR E NOTICE REQUIRED C ONS-PLEASE CALL(20';,ap <br /> SIGNED E DATE <br /> DENT <br /> EIVED <br /> 3 0 2021 <br /> 3AN 0,31QUIN COUNTY <br /> UVIRONMENTAL <br /> III DEPARTMENT <br /> a-ZI11, TMENT SE ,ONLY <br /> Application Accepted By Date ,y�"I Area-C � Employee ID#A- AI'�--l�A k-7 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date 1-1 WAIVER Received <br /> Soil Borin/Inspection By ate Constructed Well Depth ft <br /> COMMENTS(9k( �-Ce-n.0�:­ V� <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# WellID# <br /> Codes Info B Cosh- —Remitted Service Request# <br /> O <br /> V L <br /> END 43-06 6/1112019 . p G� 2 ?) b 6 WELL/PUMP PERMIT <br />