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& i +}6, Y' <br />PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP RTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT n I www.sjgov.org/ehd EXPIR �Sr �IYEAR FROM DATE ISSUED <br />JOB ADDRESS oo Rr ^ On CITY/ZIPd"LS7 <br />__ Vy�Jf%J <br />CROSS STREET /�w �APN O � 070 � PARCEL SIZE f fgLAND USE APPLICATION # <br />OWNER NAME �jC,S' fir- /f - PHONE6W-7 <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS A /go/ 1 -2,9 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTORICONSULTANT ADDRESS <br />CITY/STATE/ZIP— <br />PHONE 3'3% 42 2.S <br />CITY/STATE/ZIPZ,4/a4 13/1 47 Z <br />PHONE ✓ ` J! <br />CITY/STATE/ZIP <br />LICENSE '❑ -57 ❑ C-61 ❑ D-09 ❑ Other NUMBER.377.3 EXPIRATION DATE <br />BILLING PARTY: ❑ OWNER V NTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING:AGeneral Mineral/Coliform Bacteria (4391) A Dibromochloropropane (4392) ❑ 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 ❑ ReDlacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring (s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUC ION <br />Drilling Method)Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool [IPush Point [I Other <br />Proposed Well Depth '?, OCI, l� ft Excavation � [� in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Wetl Casing Diameter AL in Thickness/Gauge/ASTM Sched 2W 11Steel E�Kastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 /b bag/5-10 gal water) V Sand Cement 10 sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal El Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP 38ubmersible❑ Turbine ❑ Other HP 3 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 />MINIMUM 48 HOU DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED 'e- /!� TITLE/ X DATE A <br />DEPARTMENT USE ONL) <br />Application Accepted ByDate 10 7 v� <br />Grout Inspection By 9 Date <br />Pump Inspection By Gn f S t. Date �� <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Area (!51 Employee ID#FR <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth 3 <_� ft <br />PE <br />Codes <br />Sc Received Check#/ <br />Info B Cash <br />Amount <br />Remitted <br />Date <br />Permit/ Invoice # Well ID# <br />Service Re uest # <br />ga <br />> 1 6 <br />Asa <br />�o <br />00 u <br />LI3CC <br />180 <br />#L <br />o 'I 2 <br />L)3g I <br />1 SO <br />0 'I 2 I <br />4V DDLA Lk�F2 1 <br />t13c� <br />7a <br />10 '1 2 <br />�'L 2 <br />EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />