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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 />NUN-KEFUNDABLE PERMIT <br />JOB ADDRESS <br />Date Permit/ Invoice # Well ID# <br />Service Re uest # <br />S�t2O <br />CROSS STREET <br />/t. <br />OWNER NAME <br />AAAA <br />OWNER ADDRESS <br />APN <br />.orq/ehd <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />CITY/ZIP A4 +' '00 <br />SIZE J LAND USE APPLICATION # <br />PHONE ?/1 eglo '2- -K <br />CITY/STATE/ZIP <br />CONTRACTOR 4/. - �& j� c r�/IL.1G ih" APH�ONEE�,���r7n� L.1 <br />CONTRACTOR ADDRESS / V , s" �i� CITY/STATE/ZIP C17�V��� /•-r/�r' ' <br />SUBCONTRACTOR/CONSULTANT V CU 'O� PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE -IM -57 ❑ C-61 ❑ D-09 ❑ Other <br />BILLING PARTY: I OWNER 6NTF <br />CITY/STATE/ZIP_ <br />T •• 7 <br />NUMBER 3 <br />SUBCONTRACTOR/CONSULTANT <br />EXPIRATION DATE C_ 14 <br />DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) i I Dibromochloropropane (4392) i Arsenic (4393) <br />INTENDED USE omestic/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 Ac4r4ew Well , f eplacement 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 />-17''IVeW t -UMP Ll t-ump Ke IacemenL L Nump Ke air Ll Kalse vveii L:asin <br />WELL CONSTRUCTION <br />Drilling Method )Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth �« ft Excavation I in diameter ❑ Open Bottom ,2}`Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 1' in Thickness/Gauge/ASTM Sched ❑ Steel -j4P'lastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth / b f' ft [I Neat Cement (94 /b bag/5-10 gal water)Sand Cement l0% j Sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method, -Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed ByX Driller ❑ Pump Contractor El Other <br />11 Concrete Pedestal ❑Dimensions: Width 3L ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP submersible❑ 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 />MINIMUM 48 H R ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED /" _ -0 TITLE 0 �'��'�'/ 1 DATE jr— T -6,.-L-/ <br />)DE ARTMENT USE O LY / <br />Application Accepted By Date 2 2 I Area EmployeelD# <br />1 <br />Grout Inspection By Date ld �Z ❑ SPECIAL Well Permit <br />Pump Inspection Bytn�nr:Stc (Qe�t.a >VL+:L Date I ��7E?Z7� ❑ WAIVER Received <br />Soil Boring Inspection By/ Date Constructed Well D pth ft <br />COMMENTS 6lnL f�(�iG P �{' C�YDyPry &W -E' l 'jg iw� t�L�/^/n" f =� i� < <br />,n <br />-4 <br />m <br />D <br />O <br />0 <br />M <br />M <br />CO) <br />ca <br />PE EM Received Che <br />Codes Info Byn Cash <br />Amount <br />Remitted <br />Date Permit/ Invoice # Well ID# <br />Service Re uest # <br />S�t2O <br />NPpp <br />43�c 0 %) <br />1 5 Z <br />�c� <br />t PSD 5 <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />