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WELL/PUMP PERMIT <br /> 1 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> CITY/ZIP YJJ/lY <br /> 1 25 2�Q D l� q _ s <br /> CROSS STREET_ API PARCEL SIZE LAND USE AP/PPLICCATION#ry;I O <br /> OWNER NAMEr(� <br /> PHONE "I I�rU(L'r'7IOWNER ADDRESSO � 1� CITY/STATE/ZIP�O��Cj lam/7119`f1Yry-7 <br /> CONTRACTOR 1 N 1 PHONE (1� 22- &z9/ <br /> r� z 9/ <br /> CONTRACTOR ADDRESS I t CITY/STATE21P J JT 1 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRYIS�TATEIZJP <br /> LICENSE CC-57 C C-61 fl D-09 J Other NUMBER (yU Z- EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:J General MineraUColiform Bacteria(4391)[1 Dibromochloropropane(4392)E Arsenic(4393) <br /> INTENDED USE U DomestiC/Private N <br /> Irrigation/Agricultural 0 Industrial Water Quality Monitoring ': Soil Sampling/Characterization <br /> U Public Water System <br /> If different from Owner Water System Name Conrad Name or Phone Number <br /> TYPE OF WORK XNew Well Replacement Well r1 Well Alteration/Modification 0 Other <br /> 0 Monitoring Well(s) of wells :1 Soil Boring(s) Mdbodngs U Geotechnical eof borings <br /> C Out-Of-Service Well -1 Out-Of-Service Well Renewal C Cross-Connection Repair <br /> C New Pum ❑Pump Replacement C Pump Repair U Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method\XMud Rotary E Air Rotary D Auger -1 Cable Tool n Push Point E Other <br /> Proposed Wall Depth ft Excavation��in diameter Open Bottom Gravel Pack/Gravel Siz in diameter <br /> 1 Conductor Casing in diameter / Conducto asing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched� U Steel 1 Plastic !!Stainless Steel :;Other_ <br /> Grout Seal D th ft E Neat Cement(94 Ib bag15-10 gal water) Sand Cement sack mixR gal water <br /> XPenlonile(2096 solids) L Other <br /> Grout Placement Method Pumped C Free Fall 0 Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By U Driller 0 Pump Contractor Other <br /> U Concrete Pedestal DDimenslons:Width It Length It Thick in Christy Box 0 Stove Pipe <br /> Mp '1 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 /> MINIM M 4OUR ADVANCE NOTICE IRED FOR INSPE� IONS-PLIEASE CALL(209)953-7'6 L' <br /> W, 'V <br /> SIGNED 1 <br /> TITLE DATE J <br /> D <br /> 2021 <br /> OUNTY <br /> ,n m int. <br /> I�I i Ili 1, 21'.it N1 <br /> DEPARTMENT USE ONLY <br /> �7 LT AhB8 N L'� Employee ID# <br /> Application Accepted By Date l' C.R <br /> Date I h�J,�24�2—Z-- [ISPECIAL Well Permit <br /> Grout Inspection By <br /> Date '�''. WAIVER RBC@IVed <br /> Pump Inspection By ft <br /> Date <br /> Soil Boring Inspection B i Constructed Well Depth <br /> 01 <br /> COMMENTS f <br /> PE SC Received C / Amount �� Permit/ Invoice# Well ID# <br /> Caeh Remitted Service Re uest A <br /> Codes Info B <br /> a WELL TUAIP PERMIT <br /> E1104106 M1118 <br />