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V WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-KEFUNDAB <br />PEWIT <br />.s Ov. r I O LAI-llrKtS l TE U TE ISSUED <br />JOB ADDRESS <br />CROSS STREET <br />ILO <br />OWNER NAME <br />OWNER ADDRESSv <br />CONTRACTOR <br />(rFROM <br />r r O I To 21 CITYIZIP ` W c, <br />( APN O� O 4 , PARCEL SIZE )_LAND USE APPLICATION # <br />V j� !` PH/O�•N /1� s �'A� <br />q r O 0 ' CITY/STATEI P" Cts � V r 1 0 <br />'` rj) J PHONE5a Cl J 0 (91 o <br />r� <br />�/ <br />j�� )�/lv <br />• r r1v V <br />�(p y� <br />�. I) e'1 t <br />CONTRACTOR ADDRESS 'X) / I (A v <br />CITY/STATE2IP <br />PHONE 'y in <br />SUBCONTRACTOR/CONSULjANT ADDRESS - ' /P ,CI7STATE/LP <br />LICENSE C-57 V C-61 D-09 Other NUMBER«) tI'V•I/W/J/'�/'yIJJ\ EXPIRATION <br />BILLING PARTY: OWNER XCONTRACTOR SUBCONTRACTOR/CONSULTANT <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 O—er Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well <br />Monitoring Well(s) # of wells <br />Well Alteration/Modification Other <br />SoilBoring(s) #of borings Geotechnical <br />Out -Of -Service Well Renewal Cross -Connection Repair <br /># of borings <br />New 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 Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) Sand Cement 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 Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Le,Rilh ft Thick _ in Christy Box Stove Pipe <br />PUMP 4 Submersible Turbine Other HP `J Pump Set ' Iy ft Standing Water Level r --r 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 />MINI OUR AD N09D E REQUIRED F(`'��p�`.�I�IN�SSP'EnCTrIOnNSS �-/P'LEASE CALL (209) 953 Z6�7 I <br />SIGNED C J �� . )TITLE ✓ �. I V i �-(� l ! n in DATE `C J <br />w <br />DEPARTMENT 5 ONLY <br />Application Accepted By Date , 7 <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area l Employee IN <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE Sc Received Che Amount Date Permit/ Invoice # Well ID# <br />Codes Info B Remitted Service Re uest # <br />L139) OSTO 2 <br />EHD43-06 6/11/2019 <br />WELL /PUMP PERMIT <br />T <br />g <br />m <br />C <br />�v <br />1 <br />S <br />E E FNT <br />l vF6 <br />G 04 20 <br />21 <br />Qu/ <br />PqR 4k TY <br />MENT <br />