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©8t2 Caj�1� <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NOP.-REFUNDABLE PERMIT �f www.sjgov.org/ehd E IRES 1 YEAR FROM DATE ISSUED <br /> Ln <br /> JOB ADDRESS /Z v ^F n�''ff(i��" CITY/ZIP C m <br /> CROSS STREET�+`� Lai6 A N �i�IV`7`.' S D <br /> //p���J PARCEL SIZE LAND USE APPLICAATI+ON# O <br /> OWNER NAME <JC\Q+r� V'� G [ C ( )/Lu! PHONE 3�Z //� typ <br /> OWNER ADDRESS _.111014^ CITY/STATEIZIP <br /> CONTRACTOR G/s orS Lklw aL w PHHONE33`Y4 72- <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP 4-/bo PVx r <br /> SUBCONTRACTOR/CONSULTANT <br /> VI f PHONE 317`3711-0 <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE//ZZIP /f <br /> LICENSE O<C-57 ❑C-61 ❑D-09 ❑Other NUMBER 3:7;7TE `r EXPIRATION DATE C7 <br /> BILLING PARTY: ❑OWNER p4M:ONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:)(General Mineral/Coliform Bacteria(4391) Dibromochioropropane(4392)D Arsenic(4393) <br /> INTENDED USE DOmestiC/Private ❑Irrigation/Agricu@ural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ew Well ❑Replacement Well ❑Well Afteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> �❑Of�t-Of-ServIce Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> A'I�ew Pum ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 1>4d Rota ❑Air Rotary ❑Augers❑Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth r ft Excavation in diameter ❑Open Bottom "Aravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ! It <br /> Well Casing Diameter-6, in Thickness/Gauge/ASTM Sched 3,OD ❑Steel �ItPlastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth a 0 It ❑Neat Cement(94 Ib bagl5-10 gal water) 6>Wand Cement 1a• sack mix17 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method umpecl ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By riller ❑Pump Contractor�p Other <br /> ❑Concrete Pedestal❑Dimensions:Width 7 ft Length It Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ubmersible❑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. 1 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 /> MINI U�4 H ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697�t <br /> SIGNED ,!; /Tim• TITLE O ✓/� DATE <br /> YlAtNT <br /> { <br /> TEAT DP T ET <br /> St I # <br /> DEPARTMENT USE ONLY <br /> Application Accepted By j_ �- Date Area �C Employee ID# � <br /> Grout Inspection By r Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Receiv d Q <br /> Soil Boring Inspection By Date Constructed Well Depth G7 It <br /> COMMENTrS t )71 -WEei 100 TSG eLl1 OL <br /> if(g5 f U " <br /> PE SC Received Check#/ Amount Permit/ Invoice# Well ID# <br /> Codes Info A 8 Cas Data Remitted Service Request# <br /> 93FO os) / /S -Z 0 22 <br /> 1-37¢ b L Hao <br /> �)3-1 sJ 2 <br /> Ha4a 70 <br /> EHD 43-W 6/11/2019 WELL/PUMP PERMIT <br />