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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.siaov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> JOB ADDRESS Q CITYLrP <br /> .Sal m <br /> ov <br /> D <br /> CROSS STREET APN 0 ARCEL SIZESE APPLICATION# O <br /> OWNER NAME /^_C{ a.�d Johnsoln PHONE �O7^IOD/- O T- m <br /> OWNER ADDRESS (PIS CITY/STATE/ZIP, ' C'k-l/vn, C4 9�aifal <br /> CONTRACTOR �7 /�` S Inc. PONE <br /> CONTRACTOR ADDRESS 4O �/LJ 1 CC/v �(�( CITYISTATEZP f <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATEI2iP <br /> LICENSE *C-57 C-61 D-09 Other NUMBERLjln RBf(o EXPIRATION DATE <br /> BILLING PARTY: OWNER it CONTRACTOR LI SUBCONTRACTOR/CONSULTANT <br /> DOMEsnc WELL SAMPLING:a General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)El Arsenic(4393) <br /> INTENDED USE )(Domestic/Private Irrigation/Agricultural Industrial ❑Water Quality Monitoring D Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK i New Well 'sI Replacement Well Well Alteration/Modification LI Other <br /> 1,1 Monitoring Well(s) #of wells I i Soil Boring(s) If of borings I Geotechnical a of borings <br /> ❑Out-Of-Service Well D Out-Of-Service Well Renewal is Cross-Connection Repair <br /> D New Pump Pump Replacement D Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 1 Mud Rotary i i Air Rotary Auger ❑Cable Tool D Push Point i Other <br /> Proposed Well Depth ft Excavation in diameter i i Open Bottom D Gravel Pack/Gravel Size in diameter <br /> i i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad r Steel Plastic rl 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 D Pumped Free Fall D Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By 11 Driller ri Pump Contractor D Other <br /> D Concrete Pedestal L_Dimensions:Width ft Length ft Thick in ❑Christy Box C Stove Pipe <br /> PUMP 7 Submersible Turbine ._1.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 /> MINIM=A NOTICE REQUIRED FOR II�,6PECTIONS-PLEASE CALL(209)953-,7697/1 <br /> SIGNED TITLE DATE10 <br /> C- <br /> t <br /> rni <br /> N <br /> EP TMENT U E NLY <br /> Application Accepted B 'P 11I <br /> y I Date Z� Area Employee ID# <br /> Grout Inspection By Dale PECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash am tte Awice Re uest <br /> Jill <br /> EHD 43-06 8/112019 WELL/PUMP PERMIT <br />