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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />JOB ADDRESS l <br />CROSS STREET S N <br />�C I / AP <br />�/ <br />OWNER NAME I CA r ••Q- � \ �� � --(— i <br />�151� y <br />CITY%LP ''_ m <br />OO PARCEL SIZE 13 <br />_LAND USE APPLICATION# 7 <br />PHONE ✓� - V Il y <br />OWNER ADDRESS 1 1 W it j3 . Lo lh 1 �, t„_ CITY/STATE/ZIP_ <br />�7 ( <br />53 <br />CONTRACTOR A I.ry�Ck I— •Q. T ✓� S h C.. P�HONE 4�- O - S ?-q ,p - F.�) G� <br />CONTRACTOR ADDRESS V �- CITYISTATEIZIP ' 1`� \Q ['�(1 �5� O t \_a \ 3• <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE C-57 7 <br />BILLING PARTY: OWNER <br />D-09 <br />CITYISTATEILP_ <br />Other NUMBER Z:1 L I,() <br />CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />ExPIRATION DATE 17- 1 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Priv 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 <br />New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Bonng(s) _ # of borings Geotechnical <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br /># of borings <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool 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 ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) Sand Cement 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 lv <br />Concrete Pedestal Dimensions: Width ft Length hick in Christy Box Stove Pipe <br />PUMP bmersible urbine Other HP Pump Set Z ft Standing Water Level Q 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 '101 <br />48 H RAD CE NOTICE REQUIRED FOR INSPECTIONS - PLEAAACALL (209) 9533-7697 <br />TITLE _S Q—y' V , QQ. I -e Z 1^1 DATE I <br />it <br />O <br />RE YMF <br />CF jW �T <br />1 19 202? <br />Qu//V <br />E qR TY <br />NT <br />I DEPARTMENT USE ONLY <br />Application Accepted By �` Date % Area Employee ID# <br />AG <br />Grout Inspection By Date t� SPECIAL Well Permit <br />Pump Inspection B Date Z�U �.`'t2 Zi� WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS I�I� pe-frKit W 01DLWgS'7 <br />PE Sc i Received Cher. <br />Codes Info <br />Amount DatPermit/ Invoice # Well ID# <br />e Remitted rvic Re 't# <br />0 osl <br />sa <br />EHD 43.06 6/11/2019 WELL /PUMP PERMIT <br />