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. If � WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT r 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />IVIJIV-KEFUNDABLE HE <br />ARM <br />��IT <br />^ <br />JOB ADDRESS L SV V O <br />j /1a,ns— <br />CROSS STREET <br />OWNER NAME <br />WWW.SICIOV <br />06✓&J' [/. <br />APN O ��' 1 D <br />�.6L <br />na tAl'IKtb 9 YEAR FROM UATE ISSUED <br />CITY/ZIP <br />SIZE L_ LAND USE(APPLICATION #_ <br />PHONE L Z,C — <br />OWNER ADDRESS /3y, . �-'// CITY/STATE/ZIP <br />CONTRACTOR hh }F� �` A_Z_-o �) /�PHHOONE �]� ' <br />CONTRACTOR ADDRESS a ,r-+ ` 2t� /J CITYIS'rATEIZIP e4. Vg26&4. <br />SUBCONTRACTOR/CONSULTANT PHONE? <br />SUBCONTRAC <br />``G4T <br />',OR/CONSULTANT ADDRESS T CITY/S <br />^T <br />�ATE/ZIP <br />M <br />LICENSE -57 11 C-61 t] D-09 ❑l O`ther NUMBER � 9f EXPIRATION DATE��_ Z� <br />BILLING PARTY: OWNER —CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING,: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE omestic/Private n Irrigation/Agricultural ❑ 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 />rYPE OF WORK MSL New Well ❑ ReDlacement Well CI Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells a Soil Boring(s) # of borings ❑ Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal I I Cross -Connection Repair <br /># of borings <br />r>cew rump u rump Replacement u rump tlepalr u Raise Wen casing <br />WELL CONSTRUCTION <br />Drilling Method I5lud Rotary 11 Air Rotary D Auger ❑ Cable Tool ❑ Push Point El Other <br />Proposed Well Deptll 3i�o ft Excavation _I 'I— in diameter ❑ Open Bottom A-4ravel Pack/Gravel Size__ in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter C in Thickness/Gauge/ASTM Sched ?Zi 13Steel Plastic 0 Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) b4and Cementf �•� sack mix/7 gal water <br />❑ Bentonite (20% solids) Ll Other <br />Grout Placement Method 04umped D Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By 'SZriller D Pump Contractor a Other <br />D Concrete Pbdestal DDimensions: Width .-Z, ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP o<,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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />F <br />Accepted By <br />DE A' TMEN I ONLY <br />_ Date/1V// CC.. ZI <br />Area (�j� /�(/� (,t� Employee ID# <br />fcrApplication <br />Grout Inspection By <br />Date <br />SPECIAL Well Permit <br />21 2 zw <br />Pump Inspection By <br />I� <br />' y Date = 6 q 1: <br />WAIVER Received <br />2,L.4 2,q <br />Soil Boring I s ec'on By <br />COMMENTS <br />/ Date <br />Constru ted Well Depth Wr.,.s <br />ft <br />— <br />Jls-t­-6 Lf- <br />6 -(5- ZI W 0 00 1429 2 -ILD <br />T <br />M <br />D <br />rn0 <br />0 <br />rn <br />Ln <br />PE <br />Codes <br />Sc <br />Inffo <br />Received Check#/ Amount <br />B Cash Remitted <br />Permit] <br />Date Service Request # Invoice # Well ID# <br />f <br />i 80 <br />S �t- <br />21 2 zw <br />2,L.4 2,q <br />L+- <br />U 1 �0 <br />W <br />— <br />Jls-t­-6 Lf- <br />6 -(5- ZI W 0 00 1429 2 -ILD <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />