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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 ` d r rlly) X31-T CITY/ZIP m <br /> CROSS STREET , APNy 0 I /OCO PARCEL SIZELAND USE APPLICATION#AF <br /> � A <br /> OWNER NAME O s-Oti PHONE( 7 Z X17 (n <br /> OWNER ADDRESS Cr *11'f CITY/STATE/ZIP <br /> :S 3 ]// U (� <br /> CONTRACTOR ��i 4 n'asJ� `'�1, PHO/NE <br /> CONTRACTOR ADDRESS /� /�i �J CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT PHONE —2 710�/o l R <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE ,><C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER S )0_'�' EXPIRATION DATE <br /> BILLING PARTY: ❑OWNER CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:General Mineral/Coliform Bacteria(4391)* "Dibromochloropropane(4392)n Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK L�Wew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> !❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> >01'ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method>@::: lud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth2X) ft Excavation n, in diameter ❑ Open Bottom 4Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_,�' ?,Z0in Thickness/Gauge/ASTM Sched D Ell b ❑ <br /> Steel lastic Stainless Steel ❑ Other <br /> Grout Seal Depth �� ft ❑ Neat Cement(94 lb bag/5-10 gal water) Sand Cement `V, sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By Xtriller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ubmersible❑ 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 /> 2�7 <br /> HOUR ADVANCE NOTICE REQUIRED FOR,INSPECTIONS -PLEASE CALL(209) 953-7697 J <br /> SIGNED TITLE O(/�'/�6r DATE-9--L-Y- 2,/ <br /> Cxr <br /> F^,�, <br /> Fp <br /> VON , <br /> � O C <br /> DEPARTMENT USE ONLY p <br /> Application Accepted By — /`— r� L Date 01/1 d Area y q ry Employee ID# <br /> Grout Inspection By c;"L Date `0` `L0,1A11 SPECIAL Well Permit <br /> Pump Inspection By Date IJ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth 190 ft <br /> COMMENTS �Jtl�tl�< yJP�1 b ferno,lh. <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> sa .21 <br /> 00 5-3 <br /> `►3� J�"o woo LA 2S$ <br /> 13`ay 70 $ <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />