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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1 B68 EAST HA2ELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> JOB ADDRESS c^�� r. ^`R (� (/,, CITYMP <br /> CROSS STREET vt 'b r.-5 ST APN C ��I 5 D 9� PARCEL SIZEZ0 LAND USE APPLICATION# +' A <br /> �j <br /> L�✓i N /�/U PHONE J z 7 7(� Y� <br /> OWNER NAME <br /> OWNER ADDRESS ^/( CITY/STATEIZIP <br /> CONTRACTOR ,� "A - r-.sass Or.J 1.'i' <br /> PHONE <br /> CONTRACTOR ADDRESS CITYISTATE171P G )e)& (f]n..�"`t49 <br /> f�e <br /> SUBCONTRACTOR/CONSULTANT L �/.461j' 19'^P <br /> � <br /> PHONE77 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATE/ZIP //�♦ <br /> LICENSE Iy�57 0 C-61 D D-09 ❑Other NUMBER 73 C EXPIRATION DATE �'-7? ■ o <br /> BILLING PARTY: rI OWNER i11 CONTRACTOR LI SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING General Mineral/Coliform Bacteria(4391)X..Dibromochloropropane(4392) i Arsenic(4393) <br /> INTENDED USE 1KDomestic/Private Imgation/Agricultural D Industrial ❑Water Quality Monitoring 0 Soil Sampling/Characterization , <br /> 0 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK,jii:rNew Well ❑Replacement Well ❑Well Alteration/Modification 0 Other <br /> ❑Monitoring Wells) #of wells ❑Soil Borings) #of borings ❑Geotechnical #Of FlVe <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal 0 Cross-Connection RepairIi <br /> ew Pum 0 Pum Replacement 0 Pum Repair ❑Raise Well Casing4AR In <br /> WELL CONSTRUCTION <br /> Drilling Method QrMud Rotary 0 Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other F. n�oLlN Cot N <br /> Proposed Well Depth�_ft Excavation�in diameter 0 Open Bottom ❑Gravel Pack/Gravel Size I) r <br /> ❑Conducjr Casing in diameter / Conductor Casing Depth ft MFN <br /> Well Casing Diameter in Thicknelss/Gauge/ASTM Sched i-03 ❑Steel 641astic ❑Stainless Steel 0 Other <br /> Grout Seal Depth t(1 0 Neat Cement(94 Ib bag/'310 gal water) 3Aand Cement /ia sack mix/7 gal water <br /> 0 Bentonite(20%solids) ❑Other <br /> Grout Placement Method 21"Pumped ❑Free Fall 0 Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By XDriller 0 Pump Contracto ❑ Other <br /> 0 Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible❑Turbine ❑Other HP 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 /> MINIMUM 48 H UR'ey�''VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED /R1 TITLE (9(i SNL Imo"' DATE <br /> a <br /> EP RTMENT9Y <br /> Application Accepted By IG �- Date � '� Area Employee ID# <br /> Grout Inspection By �o;t,yto L(prc a g 3ti Date L11 (L� 1.1 SPECIAL Well Permit <br /> Pump Inspection By Date P WAIVER Received <br /> Soil Boring Irlspection By Date Constructed Well Depth ft <br /> COMMENTS - V <br /> tr MM4; U1111-1 -09k <br /> PE SC Received -theckM Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Re uest# <br /> ;-138o O /sa <br /> L)366 Igo <br /> LI3R I /!;, <br /> LI3ci ol O <br /> EHD 4306 6/1112019 WELL(PUMP PERMIT <br />