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3 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT www.s ov or /ena tA1"IKt, 'I YEAR FROM UATE ISSUED <br />JOB ADDRESS ...r I 7 C Si' (. � CITY/ZIP 4 � d-1- <br />CROSS STREET *0 / P /� APN IQ �7PARCEL SIZE 42— LAND USE APPLICATION # <br />OWNER NAME ` VIS A PHONE <br />OWNER ADDRESS S'/I I'►'! L CITY/STATE/ZIP <br />CONTRACTOR Zf-X U /_ 0,3 LJ /.0 11Z/ `� PHONE �> �r� L Sf <br />CONTRACTOR ADDRESS �4 JJ % k� CITY/STATE/ZIP U� "s J� L <br />SUBCONTRACTOR/CONSULTANT-0.�; fir,' PHONE L -3 �J <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE J<`C-57 ❑ C-61 ❑ D-09 ❑ Other <br />BILLING PARTY: OWNER I CONTRACTOR <br />CITY/STATE/ZIP_ <br />NUMBER 127A -` <br />J SUBCONTRACTOR/CONSULTANT <br />EXPIRATION DATE C,-- -0 <br />DOMESTIC WELL SAMPLING: iX General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) 1 Arsenic (4393) <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ 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 />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br /># of borings <br />ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method C`}>Sud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth �� ft Excavation /2 in diameter ❑ Open Bottom 21CGravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched L Ck-� ❑ Steel blastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth / +) ft ❑ Neat Cement (94 Ib bag/5-10 gal water) "*'Sand Cement 10,3 sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method I Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By Zbriller ❑ Pump Contractor J El Other <br />El Concrete Pedestal ❑Dimensions: Width �' ft Length Lr' --ft Thic in 11 Christy Box ❑Stove Pipe <br />PUMP . 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 />MI= HODU/}2 ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED /l�i0►- TITLE (7 DATE / L,' Lf! <br />—4— <br />SC <br />Info <br />DEPARTMENT USE ONLY <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Re uest # <br />' 3�0 <br />-- /`�T <br />�5� �� <br />� C ' <br />/ <br />Application Accepted By <br />Date <br />Area Employee ID#DA <br />Grout Inspection By <br />Date <br />❑ SPECIAL Well Permit <br />Pump Inspection By <br />Date 6 /� zau <br />❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />T <br />Date <br />Constructed Well Depth <br />ft <br />r <br />-4 <br />m <br />D <br />0 <br />0 <br />m <br />m <br />y <br />y <br />PE <br />Codes <br />SC <br />Info <br />Received Check#/ <br />BY Cash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Re uest # <br />' 3�0 <br />os ► <br />�.s33� <br />Asa � A <br />o <br />EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />