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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNT`( ENVIRONMENTAL HEALTH DEPARTMENT 1863 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />Itl 6Jitl-ISLrui4uAoLr r-CKIVII I <br />JOB ADDRESS <br />i <br />CROSS STREET / APN <br />OWNER NAME J" -I �-' L v7 <br />OWNER ADDRESS /lJ <br />CONTRACTOR hl.� <br />CONTRACTOR ADDRESS <br />SUBCONTRACTORICONSULTANT <br />ov.ora/ena <br />CITYIZIP <br />1 YEAR—FROM DATE ISSUED <br />i+ARCEL SIZE 1 LAND USE APPLICATION # <br />'PHONE �J <br />CITY/STATE/ZIP <br />PHONE' )"1 <br />PHONE <br />SUBCONTRACTORICONSULTANT ADDRESS CITY/STAT/E'/ZIP <br />LICENSE ❑ C-57 ❑ C-61 ❑ D-09 gLQther NUMBER L c EXPIRATION DATE ^" <br />BILLING PARTY: ❑ OWNER O'60NTRACTOR ❑ SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ 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 ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br /># of borings <br />ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched 11Steel 11Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />oncrete Pedestal El Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible❑ Turbine ❑ Other HP__ _ Pump Set_J_5�Z_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 />M NI M 48 HOURJI <br />MANCE NOTICE REQUIRED FOR 1 SPECTIONS - PLEASE CALL (209) 9 3-769 <br />' r /,, I/j 1 <br />SIGNED II AlA/V7C(M� l �f�— TITLE --� DATE <br />T <br />m <br />D <br />0 <br />0 <br />z <br />A <br />(n <br />,DEPARTMENT USE ONLY <br />Application Accepted By � �%_ Date .� a 31d 1 Area y � � Employee ID# EP <br />Grout Inspection By 1HDate I ❑ SPECIAL Well Permit <br />Pump Inspection By Date I \Z 122— ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS :Yy1D Df 0-1—" <br />PE <br />Codes <br />Sc <br />Info <br />Received Check#/ <br />Cash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />LJ3S0 <br />a ;) <br />12b7 9§ <br />�jg�2 I <br />tS <br />V <br />EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />