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a <br />tIt WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NUN-KEFUNDABLE YERMI7 <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />www.slaov.ora/ena <br />APN _kHLI0 F_� PARCEL SIZE <br />OWNER ADDRESS �/ f -h Z_ <br />4 i-� _01 1 <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE 'KC -57 ❑ C-61 ❑ D-09 <br />BILLING PARTY: ❑ OWNER <br />'_(T ci e— <br />CITY/STATE/ZIP <br />L%)KCS ' YEAR FROM UATE ISSUED <br />AND USE APPLICATION # <br />PHONES 67- e2 S,5 <br />PHONE J .S/�/���, Y7VJ <br />CITY/STATE/ZIP r_I " Z - <br />PHONE <br />CITY/STATE/ZIP_ <br />❑ Other NUMBER 7:3F -r- <br />0 <br />3 -(❑ CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br />EXPIRATION DATE C 3—__"'? <br />DOMESTIC WELL SAMPLING: L General Mineral/Coliform Bacteria (4391). Dibromochloropropane (4392) CI Arsenic (4393Qj4Y <br />INTENDED USE b<bomestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Char ��V <br />❑ Public Water System C �® <br />If different from Owner: Water System Name Contact Name or Phone NumbA l jr, <br />TYPE OF WORK KNeW Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other - • CU4 <br />❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) of borings ❑ Geotechnical R=168U <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair '" L1•H t) lVW EPAR-E <br />[�)dew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casino <br />Drilling Methodd4dlud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation ' in diameter ❑ Open Bottom ''Gravel Pack/Gravel Size- 3 in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter -6—in Thickness/Gauge/ASTM Sched 7 ?)0 ❑ Steel Plastic ❑ Stainle s Steel ❑ Other <br />Grout Seal Depth 7 ft ❑ Neat Cement (94 Ib bag/5-10 gal water) and Cement sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Methodo;Mr-Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By >iebriller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width �_ ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP &<Submersibleo Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT 1 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 />MINIMUM 48 HOU jj DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED b_ - TITLE0 C_-j_1t�� DATE - - 7 ? - Z) <br />DEPARTMENT USE ONLY <br />Application Accepted By _ Date F, a O <br />Grout Inspection By Date O 2fI -0 <br />Pump Inspection By Date J !i <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area % �� Employee ID#_ <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth � SS ft <br />T <br />m <br />D <br />0 <br />0 <br />m <br />m <br />EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />Amount <br />Rem ifted <br />EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />