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WIELL/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.sjqov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> 67/ m <br /> JOB ADDRESS CITY/ZI / m <br /> CROSS STREET /AAIPN_ V U PARCEL SIZE 61 LAND U,�S,(Ey�A�PQ1 LIGATION# 2 A <br /> OWNER NAME ✓" Y�/ V 1 P& <br /> y,�� [' PHO.NFp//�' // J y <br /> OWNER ADDRESS I P( P t/� CITY/STATEIZIP(l��/r� j� <br /> CONTRACTOR �',/�y,,Tbr CI W r r D'' PHO...-)—� %G�(�•0) / <br /> CONTRACTOR ADDRESS 'v z - I CITYISTATE/ZIAL1 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP G <br /> LICENSE XC-57 _ C-61 D-09 Other NUMBER� EXPIRATION DATE l �� <br /> BILLING PARTY: OWNER ..CONTRACTOR 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 Owner: Water System Name Contact Name ar Phone Number <br /> TYPE OF WORK XNew Well Replacement Well Well Alteration/Modification -:. Other <br /> MonitoringWell(s) #of wells SoilBoring(s) #ofbodngs Geotechnical #ofborings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Q Cross-Connection Repair <br /> New Pump a Pump Replacement Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method(Mud o a u Air Rotary Auger Cable Tool ❑Push Point Other <br /> Proposed Well Depth Q� ft Excavation Ic in diameter �Open Bottom Gravel Pack Gravel Size in diameter <br /> I COnduct Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter n Thickness/Gauge/ASTM Sch � 7 Steel %Plastic i Stainless Steel i Other <br /> Grout Seal Depth ft L i Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> /"Qentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped I7 Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> 7 Concrete Pedestal❑Dimensions:Width 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPE WN LAWS. <br /> MINIMU 48 R V NOTICE REQUIRED FOFjlJ;NSVP_�C11T.I NS- LEASE CALL(209 9 3-7 <br /> SIGNED TITLE u�V• �V DATE <br /> C�c�V ED <br /> gY202, <br /> V R0Tf- NM CDU <br /> DFpq R <br /> 7-,4 �TY <br /> PA TMENTT E N L Y <br /> Application Accepted By � , Date '7 Z71IN Area Employee ID# I�r� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By ` Date Constructed Well Depth ft_ <br /> COMMENTS 2-C )SA A }ti 1. r \\��r f1l.I Wil,• 1) V I l:iN(�� -_�--5[.�� (�i. �( D <br /> �,�•fib. <br /> PE SC Received Check#/ Amount Permit/Codes Ino Ca emitted ate .Service Re ues Invoice# Well ID# <br /> \� II <br /> EHD 4M6 61112019 / -!27 WELL/PUMP PERMIT <br /> � 12-5-7/ <br />