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r <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT( . . ov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS l (� CITY/ZIP C/f/It m <br /> D <br /> CROSS STREET APN G d S a 0 D o?F, PARCEL SIZ{✓�LJ )1 a C/LAND USE APPLICATION# O <br /> OWNER NAME V PHON�►—v _ Z _ rNii <br /> I i /// <br /> OWNER ADDRESS / Z 'Y/ CITY/STATE/ZIP ) ro -y ' _ <br /> CONTRACTOR Ly{7`� [40 <br /> /rs �J�/ J ��PHHONE 33 y `t-72 <br /> v 'f <br /> CONTRACTOR ADDRESS A �7Q/J CITY/STATE/ZIP L(/(J� &�� <br /> SUBCONTRACTOR/CONSULTANT ��(.O.t`� r PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE/ZIP � <br /> LICENSE '�TOEl C-61 ❑ D-09 ❑/Other NUMBERS?73-e( EXPIRATION DATE / <br /> v Z� <br /> BILLING PARTY: 11 OWNER SCF CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391) ❑ Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ 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 /> TYPE OF WORK-,-eNew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method4 Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other- <br /> Proposed Well Depth300 _ft Excavation in diameter ❑ Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diamete in Thickness/Gauge/ASTM Sched-L-Z7 ❑ Steel 1�&lastic ❑ Stainle Steel ❑ Other <br /> Grout Seal Depth O ft ❑ Neat Cement(94/b bag/5-10 gal water) NeSand Cement � sack mW7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method,)K-Pump&d ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By,>t Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal[]Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP >4ubmersiblell Turbine 11 Other HP_ I.,, _ 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 /> ;�I �IADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209)) 953-7697 <br /> SIGNED TITLE �}�/� j'1- DATE /^� -1-/ <br /> L � <br /> T <br /> D <br /> N <br /> E r <br /> DEPARTMENT USE ONLY <br /> Application Accepted By1` Date C Area 1 / Employee ID# 1� <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By &IzySLa CPnc'�+ C. Date I ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS -.1S 1�1 "4ell t; l? Ic6 r. plef - r c or. T11 i L1 - W t�L <br /> w w V` -V 3 Obi (4 -;" <br /> PE SC Received eck Amount Permit/ <br /> Codes Info B sh RemittedDate Service Request# Invoice# Well ID# <br /> q-S 8 o WJPrX ( 34 V.1 0 q11124P / <br /> H 3q 4 1 so tl <br /> 93-,12 $71Z) It <br /> weol Osl <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />