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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.sj_qov.orq/ehd EXPIRES 1 YEAR FROM DATE ISS D <br />m <br />JOB ADDREss ` 19 j v7 S P " rM C Yl � (—� � J � 1 r1 Cm1LP LCA., K e -Cr rA ... =1 <br />CROSS STREET -art-k) VJ rl �- APN C%�/—�,�IJ./C/ PARCEL SIZE L+ � LAND USE <br />�IAPPUCAT10N- -7#7 <br />OWNER NAME 1S't_y C� ��5 e V S h 1 (AC PHONE rll U' 'I 1 770 U 1 17 S <br />OWNER ADDRESS S CI r\ (r i CITY/STATEIZIP � CI M 7 <br />CONTRACTOR -'Jo 1 1 i I C//"`a ( 1 11 �� C PHONE r7CU f) J ti{ ,�� - / �` 7 61 <br />CONTRACTOR ADDRESS _ P -c + ""1 CITY/STATErZIP j <br />�} I - ) C A _I S �l:�J <br />ADDRESS <br />LICENSE AC -57 Li C-61 U D-09 <br />BILLING PARTY: 4OWNER <br />CITY/STATE/2JP <br />El Other NUMBER<�9 `l3 (s� _ <br />II CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br />EXPIRATION DATE � Q <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE KDOmeStictPnvate ❑ Irrigation/AgricvRural O Industrial D Water Quality Monitoring 0 Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Ownm: Water System Name Contact Name or Phone Number <br />TYPE OF WORK k,CNew Well D Replacement Well O Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells C Soil Boring(s) 7 °t b°0ngs 0 Geotechnical : of bodngs <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal D Cross -Connection Repair <br />Drilling Method AMud Rotary O Air Rotary ❑ Auger D Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth. o Jc ft Excavation �_ in diameter ❑ Open Bottom ' [travel PaddGravel Size in 4 _ in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter (�j_ in Thidcness/Gauge/ASTM Schad i_ --7c o O Steel ,P1 Plastic O Stainless Steel 0 Other <br />Grout Seal Depth �?GO ft ❑ Neal Cement (94 lb bW-1 D gal wated J}.( Sand Cement 0 , S sack mlxA gal water <br />❑ Bentonite (20% solids) G Other <br />Grout Placement Method Pumped ❑ Free Fall ❑ Other Cl Retardant / Accelerator (name) <br />PEDESTAL Installed By 'ller ❑ Pump Contractor 0 Other <br />Concrete Pedestal ❑Dimensions: Width R Length_ ft Thick In .-i Christy Bax D Stove Pipe <br />PUMP SubmersibleO Turbine ❑ Other HP Pump Set--L2-5L 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. 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 />!MUt+'t['ZE hOUR ADVANCE .40710E R20,:'RED FOR isvSPEC.TIONS "-PLEASE CALL (209)) 953-1697 <br />SIGNED �%+ ! `''+ice TITLE V� C <. 1,C S r C.t C rl DATE "1 / / <br />A TMENT U E NLY <br />Application Accepted By 75`a� Date 7 �/ <br />r <br />Grout Inspection By Al Date % t <br />Pump Inspection By Date <br />Soil Boring Inspection By Dale <br />COMMENTS <br />Area Employee ID# <br />U SPECIAL Well Permit <br />■ WAIVER Received <br />Constructed Well Depth <br />MEM� <br />e.. <br />A-e4A6 6/11/2019 - - - r r r <br />WELL RUMP PERMIT <br />