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c <br /> WELL/PUMP PERMIT PcRY jTT_ <br /> .SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON C 2(208488-3420 <br /> NON-REFUNDABLE PERMIT www.s ov..�or /ehd EXPIRES 1 UED <br /> JOB ADDRESS -I v-IP l.S V lC rV CITY21P 5-3 <br /> <C$ <br /> CROSS STREET S APN/KZ 5 c� � �- - PARCEL S VE LAND USE APPLICATION# O <br /> OWNER NAMEI-A 0', G /G 9 ' r/`�// <br /> C PHONE <br /> OWNER ADDRESS ir lV CITY/STATEIZIP LOS Rppe l a-S C <br /> CONTRACTOR PHONE 601) /1 f _'3 y <br /> CONTRACTOR ADDRESS YL� ,0 500CT/STATEZIP (1�1 51 C(9 9-SZD" <br /> SUBCONTRACTORMONSULTANT &eU cIK &KA10'-01;�" PHONE L 107 9y-Yff <br /> SUBCONTRACTORICONSULTANT ADDRESS lJ/O I�AULr/a V" CITY/STATEIZIIP I ^ <br /> r�qNa <br /> %620 <br /> LICENSE rfC-57 I C-61 fi D-09 -1 Other NUMBER //b-7 EXPIRATION DATE J) D 2 2- <br /> BILLING <br /> BILLING PARTY: it OWNER jY CONTRACTOR 7 SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:a General Mineral/Coliform Bacteria(4391)a Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USEI Domestic/Private 0 Irrigation/Agricultural f. Industrial U Water Quality Monitoring Soil Sampling/Characterization <br /> I Public Water System <br /> 0 different from Owner. Water Syslem Name Contact Name a Phone Number <br /> TYPE OF WORK New Well i i Replacement Well i Well Akeration/Modification i Other <br /> -1 Monitoring Well(s) #of wells r Soil Boring(s) If of boring' Geotechnical 7 of bohngs <br /> Out-Of-Service Well i_ Out-Of-Service Well Renewal Cross-Connection Repair <br /> 7 New Pump 7 Pump Replacement U Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 7 Mud Rotary 11 Air Rotary J Auger U Cable Tod --Push Point C Other <br /> Proposed Well Depth I S it Excavation in diameter C Open Bottom C Gravel Pack/Gravel Size In diameter <br /> 7 Conductor Casing in diameter / Conductor Casing Depth It <br /> Wall Casing Diameter_In Thickness/Gauge/ASTM Schad L Steel _Plastic C Stainless Steel C Other <br /> Grout Seal Depth R ;l Neat Cement(941b bag/5-10 gal water) Sand Cement sack mlxl7 gal water <br /> -I Bentonite(20%solids) n Other <br /> Grout Placement Method :)Pumped j Free Fall -1 Other Retardant I Accelerator(name) <br /> PEDESTAL Installed By C Driller C Pump Contractor U Other <br /> 7 Concrete Pedestal❑Dimensions:Width ft Length fl Thick In U Christy Box C Stove Pipe <br /> PUMP 7 Submersible[j Turbine U Other HP Pump Set it 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 /> I UM 48 H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE <br /> r If <br /> �VFd <br /> ?421 <br /> /N <br /> ENC)V NTY <br /> A <br /> ART MENT <br /> /DEPARTMENT U E1 NLY ,1) / <br /> Application Accepted By a Data / i'i Are D"1 /05 Emplo�ea&D# <br /> Grout Inspection By Date U SPECIAL Net'Permit <br /> Pump Inspection By Date U WAIVER Received <br /> Soil Boring/�pspectlon By Date Constructed Well Depth ft <br /> COMMENTS / �9J�iAc/ d.7 Z`� `) O/�1-G(p eht 0.7 1� %--O/C, <br /> PE SC Received Check#/ Amount ate Permit/ Invoice# Well ID# <br /> Codes Info Ca h Remitted S rvice gisuest# <br /> /37 /,SL' �D <br /> EHO 4]d6 BI112019 WELL(PUMP PERMIT <br />