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WELUPUMP 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.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> to <br /> JOB ADDRESS cC\n"E . CYZP <br /> 'V �7PARCELSIZE IU QLAND USE APPLICATION T�FIO'NCROSS STREET L� - � - C - ( q�D <br /> Y (� oA <br /> OWNER NAME "t CI r I.J'Z `n l G� J PHONE 4 C,'� - � 1 7 <br /> a <br /> OWNER ADDRESS CI M u� CfT/ISTATEMP �CI M C "J <br /> CONTRACTOR i I 1` 1 l� f 1 `1 t L� PHONE � -7C r���[`CI '/^ /-79 <br /> CONTRACTOR ADDRESS C, �� C'X CITYISTATEZP &Ci 1�- I C CI Slam' <br /> SUBCONTRACTOR/CONBULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CRY/STAAT(E/ZJP �7 <br /> LICENSE �,C-57 J C-61 L D-D9 L Other NUMBER x.73 EXPIRATION DATE / 3 I - <br /> BILUNG PARTY: i'OWNER CONTRACTOR fl SuBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAM PLING:AGeneral Mineral/Coliform Bacteria(4391)Dibromochloropropane(4392)L Arsenic(4393) <br /> INTENDED USE Domestic/Private "Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> Ir deerent f—Owmer. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK �(,New Well Replacement Well Well Alteration/Modification i i Other <br /> Monitoring Wells) A of wells L Soil Boring(s) flof bonnge Geotechnical •of bonngs <br /> L Out-Of-Service Well Out-Of-Service Well Renewal I]Cross-Connection Repair <br /> New Pum -i Pump Replacement ra Pump Repair L Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method'$Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth 3;(3 It Excavation Ij in diameter Open Bottom )(Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad C C C' -:Steel '(Plastic Stainless Steel Other <br /> Grout Seal Depth 10 C ft i Neat Cement(94 Ib bag/5-10 gal water) Sand Cement `G o sack mix(7 gal water <br /> L;Bentonite(20%solids) c Other <br /> Grout Placement Method - Pumped L Free Fall L Other -_Retardant/Accelerator(name) <br /> PEDESTAL Installed By `' Driller L Pump Contractor - Other <br /> Concrete Pedestal_Dimensions.Wdth 4 It Length ft Thick in E Christy BoxStow Pipe <br /> PUMP Submersible j Turbine 'J Other HP i Pump Set tt Standing Water Level i 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 /> MINIMUM <br /> /48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)`953-7697 <br /> SIGNED L b vV�n TITLE C:++ "C DATE 1 G <br /> PAYMENT <br /> 47— RECEIVED <br /> h <br /> OCT 19 2021 <br /> 1 <br /> AN JOAQUIN COUNTY, <br /> ENVIRONMENTAL <br /> iF.ALTH DEPARTMENT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By �- tel"4-" Date �� �e%/�� Area a' 'I ' Employee ID# r <br /> Grout Inspection ByA.04--kDate V Z.t - ( I SPECIAL Well Permit <br /> Pump Inspection By IDate 1 'li 11 WAIVER Received <br /> Soil Boring Inspe on By Date Constructed Well Depth ft <br /> COMMENTS ( ( I;r• T(' t.1 NI!•!r'Iv;1^ cA Is} I, i's - <br /> C' V1 C"I&L, cjh,.T r' -C. i7.x <br /> r <br /> PE SC RecaIV d Check#f Amount Date Permit/ Invoice N Well IDN <br /> Codes Info B ash Remitted Service Re uestA <br /> 3 L+J 1 1�0 <br /> V' <br /> -13 <br /> IF DOX <br /> ar'I <br /> t. C, .O <br /> EMO13-06 61112019 / Q h , / ,2�ZU'PPERM" <br />