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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMVVELL/PUMP PERMIT <br />ENT ....... - 1868 EAST HAzeLTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />Joe ADDRESS - <br />CITYI7JP o� <br />CROSS STREET APNL) S 'l <br />�! PARCEL SIZE I'S Cy <br />LAND USESAPPPLIICATION# <br />OWNER NAME PHON4209I q 72 - Zkq / <br />OWNER AODRESS _AW/$ F �i/�'A'Y/� <br />�• 1111 L!/�lY CITYISTATE21P'`_��'V <br />CONTRACTOR <br />.CONTRACTOR ADDRESS PHONE2rt�� -j-� <br />CITY/STATE/ZIP <br />SUBCONTRACTOR/CONSULTANT <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />/STATE/ZIP <br />LICENSE C-57 C-61 _ p_0g j, Other <br />NUMBE E%PIRATION DATE <br />BILLING PARTY:_. OWNER <br />CONTRACTOR SUBCONTRACTOR/CONBULTANT <br />DOMESTIC WELL S�MPLING: —' General Mineral/Coliform Bacteria (4391) - Dibromochloropropane (4392) � Arsenic (4393) <br />INTENOrD USE KDomestiripri,intp1 r _ <br />- - - -•-• d <br />Public Water System vvafer uuauty Monitoring - Soil Sampling/Charederizetion <br />- <br />If different from Owner Water Sysiem Name <br />Contact Name or Phone Number <br />- - — uvea Replacement Well - Well Alteration/Modification <br />C Other <br />Monitoring Well(s) # of wells ❑ Soil Boring(s) to of borings <br />Out-OfSem.ceiVell Geotechnical a of borings <br />Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement Pump Rapair <br />Drilling Method _ Mud Rotary ;� Air Rotary Auger Cable Tool _ Push Point <br />Proposed Well Depth fl -: Other <br />Excavation In diameterOpen Bottom C Gravel Park/Gravel Size <br />Conductor Casing In diameter / Conductor Casing Depth in diameter <br />Well Casing Diameter _ in Thirkness/Gauge/ASTM Schad 0 <br />Grout Seal Depth ft Steel Plastic _Stainless Steel Other <br />Neat Cement (9416 bag/5-10 gal avatar) � Sand Cement <br />Bentonite (20% solids) = Other sack m/xq gal Water <br />Grout Placement Method 7 Pumped - Free Fall Other <br />Rwtardanr r e�..adn <br />Installed By -. Driller Pump Contractor - Other <br />Concrete Pedestal C:Dlmensions: Width it Length fl Thick <br />Christy Box - Stove <br />L m. gsupmersihle Turbine - Other HP Pump Sat <br />g Water Level . it <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 />WORKEIj6NMPENSATION LQ MS's <br />DEPARTMENT USyyE. ONLY <br />Application Accepted By �Date �r7 <br />Grout Inspection By Date �-y �— <br />Pump Inspection By �[ /�} t" L I t �/ L/� • " Date <br />Soil Boring inspection By <br />COMMENTS <br />Date <br />( G� <br />Area i Employee ID: 1141 <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />_Ln <br />M <br />0 <br />a <br />N <br />AYMENT <br />ECEIVED <br />AUG 12 2021 <br />N JOAQUIN COUNTY <br />ENVIRONMENTAL <br />_ALTH DEPARTMENT <br />VrLL 1PU1.'P PERMIT <br />