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�J <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDAB /, pWWW.S 0V. r /ehd �E/X��PII^,RESSJIYE FROMDA IS ED <br />JOB ADDRESS I L V )\ JY `j CITY/7JP "l, o 00 G <br />CROSS _-- � V i k I t-uq <br />u � L'�-��/—/� �APPN d07l 0 -` V - L) PARCEL SIZE ro• � USEt/APPLICATION # <br />OWNER NAME r ,/ L <br />OWNER ADDRESS I 1 I / / C /STA O `/ G� ,I f \/ <br />CONTRACTOR T— • G`P n U PHHPN�E <br />It)'Ar <br />CONTRACTOR ADDRESS • 1 4E61 CITY/STATE/ZIP 1 t� <br />SUBCONTRACTOR/CONSULTANT VIV_ PHONE 1 <br />SUBCONTRACTOR/CONSU��L/T//�_1T ADDRESS I, CITY/STATE1I/ZZIP <br />LICENSE C-57 C-61 D-09 <br />Other �� Num (10' `1 EXPIRATIDN DA <br />BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WEL 5 <br />FPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE omesfc/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner. Water System Name Contact Name a Phone Number <br />C -1- <br />10 <br />c <br />10 <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />■■■{�■■■■■■■■■■�i'UG / <br />■{�■■■■■■■■�a■•02 <br />• <br />Area Employee ID#DEP <br />SPECIAL Well Permit <br />WAIVER Received <br />Monitoring Wallis) #of wells SoilBoring(s) 0ofborings Geotechnical nofborings <br />Soil Boring Inspection By Date <br />Out -Of -Service Well- rvice Well Renewal Cross -Connection Repair <br />_ New Pum Pum Replacement Pum Re air Raise Well Casing <br />WELL CONSTRUCTION 13 II •%� I- — /� D 7 <br />v �C I <br />Drilling Method Mud Rotary Air Rotary Auger Push Point Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth It Neat Cement (94 lb bag6-10 gal water) Sand Cement sack mix17 gal wate <br />Bentonite (20% solids) Other <br />C i <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Ins Iled By Driller Pump Contractor Other <br />oncrete Pedestal Dimensions: Width ft Le h ft Thic in Christy Box Stove Pipe <br />4Z <br />if 11 <br />PUMP V 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 I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. ( <br />( <br />M M 48 �R ADV NOTICE REQUIRED FO•R�\WSPE ICTTIIO/NS-}PLL�EASE CALL (20157-7697/17 G <br />SIGNED ��� TITLE Vtr/V / 0, 1 / ,(- -. DATE2,V 1 L I <br />r— <br />■■■NEEM■■■■■■■■■■ ■■■NEM■■ <br />■■■■■■■■■■■■■■■■■■■■■w■■■■■■E■ <br />■■■{�■■■■■■■■■■�i'UG / <br />■{�■■■■■■■■�a■•02 <br />• <br />Area Employee ID#DEP <br />SPECIAL Well Permit <br />WAIVER Received <br />DEPARTMENY USE ONLY <br />Date <br />Grout Inspection By Date <br />Pump Inspection By .nDate 4116 1Z I- <br />Soil Boring Inspection By Date <br />epth ft <br />Constructed Well DCOMMENTS <br />� <br />EHD43-06 6/112019 WELL /PUMP PERMIT <br />