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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 www.sjgov.oEg/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> /`O \1-n J 7 N <br /> JOB ADDRESS MOO <br /> J�C� r l G1 Q CITY2JP <br /> r I J 1 mD <br /> CROSS STREET_ ,k�G`V�-}-U�l {LS'�] J� APN`C) I-U — 7_7PARCEL SIZE IO'IC LAND USE APPLICATION/# <br /> OWNER NAME 1 Cl Y- LJ-Q,'0 7 PHONE <br /> w <br /> OWNER ADDRESS �C�MUe CITYISTATEIZIP <br /> CONTRACTOR CI, l 10 'r 1 " {Y�l � PHONE e?C,�I ?G,CI ` vS'77q <br /> CONTRACTORADDREss �.Cr , 13 CSX 4,^( CM1STATEI7IP (:2,1 !^ L, JC <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CII�TUY/STAATEErZIP <br /> LICENSE A C-57 0 C-61 0 D-09 0 Other NUMBER of 1 JS-J EXPIRATION DATE=.-,3 <br /> BILLING PARTY: 0 OWNER CONTRACTOR Cl SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAM PLING:AGeneral Mineral/Coliform Bacteria(4391),Dibromochloropropane(4392)L7 Arsenic(4393) <br /> INTENDED USE Domestic/Private D Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soll Sampling/Characlenzation <br /> D Public Water System <br /> 11 dRerent hom Owner Water System Name Contact Nenn or Phone Numher <br /> TYPE OF WORK �A New Well C Replacement Well 0 Well Alteration/Modification P.Other <br /> D Monitonng Well(s) #ofwells 0 Soil Boring(s) eo1bonng 0 Geotechnical /orbonngs <br /> 0 Out-Of-Service Well 13 OUI-Of-Service Well Renewal a Cross-Connection Repair <br /> %Newpump 0 Pump Replacement ❑Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method' Mud Rotary D Air Rotary C Auger U Cable Tool n Push Point D Other <br /> Proposed Well Depth ';L�6 ft Excavation 1�2_in diameter 0 Open Bottom )(Gravel PaWGravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_Q2_in Thickness/Gauge/ASTM Schad C)r�G CI 0 Steel �(Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth 10 U It 0 Neat Cement(94 lb bag/5-10 gat water) Sand Cement `f).o7 _sack mix/7 gal water <br /> Ii Bemonite(20%solids) 0 Other <br /> Grout Placement Method Pumped 0 Free Fab 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL I stalledByDriller 0 Pump Contractor0 Other <br /> `�Concrete Pedestal ODimenslons:Width 4 ft Length It ThickIn 0 Christy Box ❑Stove Pipe <br /> PUMP Submersible l7 Turbine 0 Other HP I Pump Set 1t Standing Water Level Ift <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'aIMUP: 8 HOUR <br /> �A^^D:rANCE I:OTICE REQUIRED!'OR U'dSr=cCTIQN; -?Li_ASE CALL(209)953-7597 <br /> SIGNED `'J" ,vV Vim, TITLE C)F-k C'C. r <br /> DATE G <br /> PAYMENT <br /> RECEIVED <br /> OCT 19 2021 <br /> SAN JOAQUIN COUNTY, <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> -ATT H I I I <br /> NT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date !J 1"/ / Area 9 �t(i Employee ID# r <br /> Grout Inspection By A.) Dete . ( 0 SPECIAL Well Permit <br /> Pump Inspection By Date 0 WAIVER Received <br /> Soil Boning Inspe(bion,By / Date Constructed Well Depth ft <br /> COMMENTS {1 {'�c,I ,e, Cl -01P) r %;A-! ��T1 ,n •� or c,►iln"�; I <br /> J��rqJ. C.(:Y'C I -t-• r j 7 "1 S J 1 rT e :C U re Y1 L ray <br /> PE -SC Receiv d Cheek#! Amount Date Permit/ Invoice Well IN <br /> Codes Info eah Remitted Service Re uestN <br /> 3o�1 1ST <br /> 78 do <br /> c, p <br /> EHb I3-O6 6/11/2019 � � � � � 2—Q � �� �D / / <br /> I Y WELL/PUMPPERMrT <br /> Zv 2 <br />