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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 PEERM�IIT/ A/� WWW.s ov.or lehd /�EXPIRE/JS 1 YEAR FROMDATEISSUED <br /> JOB ADDRESS fX L�OL J o / 1 Ut�Yl u I lo ��I Gh i CITY/ZIP .A C a M 1 0 1 CA <br /> m <br /> CROSS STREET C JCI I ICC R I,7. APN PARCEL SizEo7 AC LAND USE APPLICATION# o <br /> OWNER NAME `�� ` 'U ` '��1` I PHONE <br /> OWNER ADDRESS I \E Ci TYISTATEMP <br /> CONTRACTOR , L�1 1 f n L� PHONEr✓�j1 <br /> CONTRACTOR ADDRESS �.C� - iJG' 7E CITYISTATE17JP Cycd_�_, \ <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SU13CONTRACTORICONSULTANT ADDRESS CITY/SdTATEZP ? <br /> LICENSE 'A C-57 D C-61 D D-09 LJ Other NUMBERI {j. } EXPIRATION DATE -f <br /> BILLING PARTY' C OWNER CONTRACTOR L SUBCONTRACTORICONSULTANT <br /> DoMesnc WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE DomesticlPrivate ❑Irrigation/Agricultural 0 Industrial ❑Water Quality Monitoring 0 Soil Sampling/Characterization e <br /> ❑Public Water System ��- <br /> I(diff—rit from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK C(Vew Well 0 Replacement Well 0 Well Alteration/Modification D Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) 4 of borings 0 Geotechnical z or Eorings <br /> L Out-Of-Service Well 3 Out-Of-Service Well Renewal 'J Cross-Connection Repair <br /> New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method' Mud Rotary 0 Air Rotary F,Auger D Cable Tool ❑Push Point D Other <br /> Depth Proposed Well <br /> p p ,�� ft Excavation_�r.( in diameter F Open bottom YGravel Padc/Gravel Size 1/4 in diameter <br /> C Conductor Casing in diameter / Conductor Casing Depth IT <br /> Well Casing Diameter in Thickness/Gauge/ASTM SchadC - fit 0 Steel ')kPlasbc 0 Slainless-teel D Other <br /> Grout Seal Depth t7J it .]Neat Cement(94 lb bagl5-10 gal water] )(Sand Cement I 0 _2 sack mixR gal water. <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method Pumped D Free Fall ❑Other C Retardant!Accelerator(name) <br /> PEDESTAL 1 stalled By tiller C Pump Contractor ❑ Other _ <br /> Concrete Pedestal LL]Dlmenslons:Wdth Zft Length - ITThickin D Christy Box [IStove Pipe <br /> PUMP Submersible Turbine CI Other HP Pump Set ft Standing Water Level C.C 8 <br /> I HEREBY CERTIFY THAT 1 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 /> d5i,:W,Ur. 48 HOUR ADW1,N:s= OTiCF_kEC-UIRED OR'-'Sp=CTI0EdS-P'_EASE CALL.(2n)053-I69i <br /> SIGNED 1'pl�M TITLE (:)-k � t C(-� DATE C� <br /> Ir <br /> ��YMFN <br /> a 8 2a2� <br /> k. 0//V C <br /> ovjq <br /> TY <br /> - d t FNr <br /> �,�✓� PA TMENT U E O Y <br /> Application Accepted 8 ate Area4�L� Employee <br /> Grout Inspection By Date ❑ PECIAL Well Permit <br /> Pump Inspection By Date J WAIVER Received a,t <br /> Soil Boring Inspection By Date Constructed Well Depth z p 6 ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permltl Invoice# Well ID# <br /> Cod Ifo a Ch Remitted rvirpR ueet# <br /> z7jxZ drP6 0. <br /> E D4S-06 6/17/2019 WELLIPUMPPERMn <br /> 7�S <br />