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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95206-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> r LA <br /> JOB ADDRESS O r h a T CITYIZIP �7� m <br /> D <br /> CRObS STREET �? APN 00717030 PARCEL SIMX LAND USE AP7P�LIIC�ATION#,Q <br /> OWNER NAME O �Oti PHON E�r/7 <br /> f Vl <br /> OWNER ADDRESS " .� CITYISTATE/ZIP <br /> CONTRACTOR �)) V/ J�/-as-� �PHO�NE r3 <br /> CONTRACTOR ADDRESS Orb <br /> y /�% `�� CITYISTATE/ZIP [�/L��/.9/1-(!/Q�' 11✓V// <br /> SUBCONTRACTOR/CONSULTANT�C/� (��S/dSJ PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATEIZIP <br /> LICENSE ,-<C-57 ❑C-61 ❑D-09 0 Other NUMBER �TZ)E EXPIRATION DATE <br /> BILLING PARTY: 0 OWNER )J CONTRACTOR 0 SUBCONTRACTOR/CONSULTANT W.v� <br /> DOMESTIC WELL SAMPLING:,)]General MineraifColiform Bacteria(4391) 'Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private D Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring D Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Omer. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK Lq2 Well ❑Replacement Well 0 Well Alteration/Modification ❑Other <br /> s0 Monitoring Well(s) #of wells 0 Sol[Boring(s) #of borings ❑Geotechnical u of borings <br /> ❑Out-Of-Service Well ❑Out-Of--Service Well Renewal ❑Cross-Connection Repair <br /> ew Pump ❑Pump Replacement 0 Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method>r-*ud Rotary D Air Rotary 0 Auger ❑Cable Tool 0 Push Point ❑ Other- <br /> Proposed Well Depth2oi?O It Excavation 0?2� _in diameter 0 Open Bottom 4Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter J!� �in Thickness/Gauge/ASTM Schad 30 Steel bOlastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ,M ft ❑Neat Cement(94 Ib bag/5-10 gal water) Sand Cement <V. sack mixl7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method Pumped ❑Free Fall ❑Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller 0 Pump Contractor ❑ Other <br /> D Concrete Pedestal❑Dimensions:Width ft Length it Thick in 0 Christy Box ❑Stove Pipe <br /> PUMP ubmersible❑Turbine D Other HP Pump Set ft Standing Water Level It <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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MIN M 4 HOUR ADVANCE NOTICE REQUIRED FOR <br /> /INSPECTIONS-PLEASE CALL(209)953-71697 <br /> SIGNED TITLE 0 L/" DATE 9�Z//— 2,1 <br /> FT <br /> O <br /> q <br /> ! O C <br /> DEPARTMENT USE ONLY / G <br /> Application Accepted By ! tZt,,-L 094 Date 7 a7 Area y!q 1 Employee ID# FR <br /> Grout Inspection By `Srt-anLM% Date kQk eWkVtit ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth 0 ft <br /> COMMENTS EXIS'}IN14 Wel �0 feYVU',rYl _. <br /> PE SC Received Check#/ tmfttt Date Permit/ Invoice# Well ID# <br /> Codes Info B d Service Re uest# <br /> 938o osl •21t 37$ 190 •2 0042543tl3q I W 00 253 <br /> LI 390 $ <br /> EHD 4306 61112019 WELL(PUMP PERMIT <br />