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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 PE(RMI)T <br />OV.Ot /ehd <br />tXNIKtJ YEAR FROM DArTTL I551.1tU <br />M, /JWWW.S <br />JOB ADDRESS �D /,/ 'v O I Ot r: <br />CITYff�LAND <br />1I <br />CROSS STREETV ✓ r APN PARCEL SIZE ( <br />PPL�I}CA7TION # <br />" ��L <br />Date j <br />PHONE 7J1—i�-q9 <br />OWNER NAME �/ <br />COMMENTS <br />OWNER ADDRESS -S ti M'f <br />CIN/STATEMP <br />I �' W <br />!CONTRACTOR OCV MCn/� ,1-f <br />[' <br />J <br />/9l <br />PHONE - 1 -Z..?t (� <br />f� <br />CONTRACTOR ADDRESS 2-0'0 L"'JCCS <br />CITYISTATE21P <br />SUSCONTRACTOWCONSULTANT <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS r� <br />i�1CITYISTATE21P <br />o * I <br />LICENSE 4C-57 ❑ C-61 ❑ D-09 ❑ Other <br />NUMBER( - <br />EXPIRATION DATE <br />BILLING PARTY: 0 OWNER ❑ CONTRACTOR G SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: G General MineraUColiform Bacteria (4391) G Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural 0 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 ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />G Monitoring Well(s) # of wells ❑ Soil Boring(s) a of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump S Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />C Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched C Steel ❑ Plastic ❑ Stainless Steel C Other <br />Grout Seal Depth ft 0 Neat Cement (94 Ib bag15-10 gal water) ❑ Sand Cement sack mixl7 gal water <br />C Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other C Retardant /Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP 1 Submersible❑ Turbine D Other HP � .Z 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 />MI N 411 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE ref1 2'H h DATE 3 1-21 <br />PAYMENT <br />RECEIVED <br />MAR 2 2 2021 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />G[IdGD <br />22 2021 <br />=NTAL HEALTH <br />/SERVICES <br />Area Employee ID# 1A t <br />PECI L Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />EHO 43-M 61112019 WELL /PUMP PERMIT <br />PRTMEN T SE' NLY <br />Application Accepted By. <br />Date Z� <br />Grout Inspectlon By <br />Date <br />Pump Inspection By { < i7�A[ <br />Date j <br />Soil Boring Inspection By <br />Date <br />COMMENTS <br />PAYMENT <br />RECEIVED <br />MAR 2 2 2021 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />G[IdGD <br />22 2021 <br />=NTAL HEALTH <br />/SERVICES <br />Area Employee ID# 1A t <br />PECI L Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />EHO 43-M 61112019 WELL /PUMP PERMIT <br />