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4 <br /> 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 /> ----? S, <- ,�nf <br /> JOB ADDRESS 2 CITY/ZIP e_-,4f- 1 m <br /> P^ <br /> CROSS STREET Lor_ ii^^'h APN PARCEL SIZE L✓�D LAND USE APPLICATION# o <br /> m <br /> OWNER NAME Z-f llJ Z/d A -r/V PHONE Z <br /> OWNER ADDRESS <br /> 'A r CITY/STATE/ZIP -•� <br /> CONTRACTOR J_an s r or% I•- 1 J PHONE 15->�r` <br /> CONTRACTOR ADDRESS /"J U S)� L //�� ,Q CITY/STATE/ZIP Z4_. tx. CAI.A%p�v}�, <br /> SUBCONTRACTOR/CONSULTANT PHONE 7 qJ- L <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE 57 C-61 D-09 Other NUMBER i�J y}�.��\ 1 <br /> J EXPIRATION DATE <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING(General Mineral/Coliform Bacteria(4391)KDibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE QKDomestic/Private Irrigation/Agricultural 1_I Industrial I.! Water Quality Monitoring �_I Soil Sampling/Characterization <br /> i Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ,)eNew Well _ Replacement Well l� Well Alteration/Modification I! Other <br /> ■ _ <br /> I Monitoring Well(s) #of wells i! Soil Boring #of borings s) i� #oftitz <br /> Geotechnical v <br /> I I Out-Of-Service Well i_ Out-Of-Service Well Renewal I Cross-Connection Repair Ii <br /> ew Pump a Pump Replacement a Pump Repair I I Raise Well Casing '7A'Y <br /> WELL CONSTRUCTION <br /> Drilling Method $eMud Rotary 1 I Air Rotary ❑ Auger ' Cable Tool Il Push Point Other F 1Z_y/NN <br /> Proposed Well Depth �ft Excavation � in diameter Open Bottom ! Gravel Pack/Gravel Size THDRp r <br /> i Conductor Casing in diameter / Conductor Casing Depth ft TMEN <br /> Well Casing Diameter f in Thickness/Gauge/ASTM SchedZ 413 Steel L001astic - Stainless Steel i Other <br /> Grout Seal Depth &aO 6 LL Neat Cement(94 lb bag/5-10 gal water) Y-and Cement sack mix/7 gal water <br /> I Bentonite(20%solids) !I Other <br /> Grout Placement Method PePumped __ Free Fall - Other iL Retardant/Accelerator(name) <br /> PEDESTAL Installed By >eDriller Pump Contracto - Other <br /> Concrete Pedestal❑Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP __ yXQ ubmersible[l Turbine 11 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/ VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209) 953-7697 <br /> SIGNED ■ F TITLE lA'Ar` DATE <br /> ,/ EP RTMENT SE, ONLY <br /> Application Accepted By Date G ?tiY Area Employee ID# <br /> Grout Inspection By OAL, LJ Date �i�'I,�t�Ll SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring I spection By Date Constructed Well Depth LY Z'5- ft <br /> COMMENTS i). <br /> Y <br /> PE Sc Received heck Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted I Service Request# <br /> L)3,yo ZSIS3 I� <br /> X13 06 0 W <br /> �I3G I f/5 <br /> O <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />