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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.org/ehd /EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS .��zU � � I /,G j l /r'�+ CrTY/ZIP C- L� I%'7� Jl! 4 5 V` /S <br />CROSS STREET-Tr/fA. &eV qj• APN oZ3_'/6.0 PARCELSIZELAND USE[�APPLICATION# <br />OWNER NAME V4 V? D f L/ 5n' LPr-N r40 N I PHONE <br />OWNER ADDRESS BD/� 7LSI CITY/STATEMP ��,• �� r <br />CONTRACTOR d*Mj6FA ? SrNs i�v'C� /1 PHONE Q ` <br />CONTRACTOR ADDRESS/Ai3 OV t�yG1 `T• CITYISTATE21P 5ONP/?y4 19 4-0 <br />SUBCONTRACTORICONSULTANT PHONE <br />TRACTORICONSULTANT ADDRESS <br />Y(C-57 n C-61 r D-09 n other <br />PARTY: U OWNER U CONTRACTOR <br />CITY/STATE/ZIP <br />NUMBER ,/ A S • 0 EXPIRATION DATE <br />L SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: Ll Ueneral Mineral/GOIITorm bacteria (43&1 ) L UIDrornocnioropropane t43&YJ U Hrsenic t43&3) <br />INTENDED USE DOmestic/Private 0 Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characteriiatlon <br />D Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK (New WBII 7 Replacement Well ❑ Well Alteration/Modification D Other <br />0 Monitoring Well(s) #ofwells 0 Soil Boring(s) #or borings D Geotechnical #of boring. <br />0 Out -Of -Service Well 0 Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />D New Pump D Pump Replacement J Pump Repair L Raise vveu casing <br />WELL CONSTRUCTION <br />Drilling Method )( Mud Rotary C Air Rotary 7 Auger D Cable Tool C Push Point C Other <br />Proposed Well Depth DO It Excavation 12 in diameter 7 Open Bottom 0 Gravel Pack/Gravel Size 3 in diameter <br />I i Conductor Casing !G in diameter / Conductor Casing Depth 5b0 ft <br />Well Casing Diameter /P In Thickness/Gauge/ASTM Sched 5bA1 j 7 Steel Plastic D Stainless Steel D Other <br />Grout Seal Depth y by It n Neat Cement (94 lb bag/5-10 gal water) -1 Sand Cement sabk mix17 gal water <br />Bentonite (20% solids) C Other <br />Grout Placement Method Pumped C Free Fall 0 Other C Retardant / Accelerator (name) <br />PEDESTAL Installed By D Driller <Pump Contractor 7 Other <br />U Concrete Pedestal flDime sions: Width ft Length It Thick in L Christy Box L Stove Pipe <br />PUMP I I Submersible I Turbine i 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE 15 <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS CO ENSATION LAWS. <br />MI UM <br />H1ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED v TITLE / �p�/�% DATE Z��LOZ O <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />RA TMENT U E N��L//Y�� <br />ate _ v` <br />2Lt; L Date t ' <br />Date <br />Date <br />AreaEmployee ID#� <br />❑ PECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />EHO 43-06 6/11/2019 'WELL /PUMP PERMIT <br />n® <br />® r. <br />EHO 43-06 6/11/2019 'WELL /PUMP PERMIT <br />