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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-RI'FIINnam F PFRMIT un.nu c:...........1-6.4 CUM— ^ <br />JOB ADDRESS <br />{^�/� �j Q CITY0 p� <br />P cf5 <br />CROSS STREET <br />y�r1, <br />S//�t y�/•7(f/ APN ,-No3aaoog PARCELSIZE q.1LAND USE APPLICATION# <br />OWNER NAME <br />PHONE <br />OWNER ADDRESS <br />h CITY/STATE/ZIP <br />CONTRACTOR <br />^ e /J <br />tlP,HJO—N-E/ <br />CONTRACTOR ADDRESS CITYISTATEIZIP I� i J�/�♦ C . g..J)1 <br />SUBCONTRACTORICONSULTANT _ PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATE/Z1P <br />LICENSE C-57 C-61 D-09 Other NUMBEI�i-�--� EXPIRATION DATE <br />BILLING PARTY: <br />OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELLS • General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED U <br />DomestiGPriv3t Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />�eVdater S sem <br />It different from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK <br />New Well ee7lacement Wel Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Borings) # of borings Geotechnical # of borings <br />Out -Of -Service W Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump 4PumpReplacemenl Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method <br />Proposed Well <br />Mud Rota Air Rotary Auger Cable Tool Push Point Other <br />Dept, ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Con or Casing in diameter / Conductor Casing Depth ft <br />Well Casing <br />Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal <br />Depth It 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 <br />Installed By Driller Pump Contractor Other i I <br />Concrete Pedestal Dimensions Width It Length ft Thick in Christy Box Stove Pipe <br />y <br />m <br />m <br />g <br />N <br />r <br />J <br />1W <br />4.I <br />.-D <br />PUMP Subme a Turbine Other HP Pump Set ft Standing Water Level ft O <br />I HEREBY HAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK MLL BE DONE IN ACCORDANC TH 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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINI U 48 H ADV &E NOTICE REQUIRED FOR PJSJSP`E'CjTie <br />- PLEASE CALL (209) 9�53-7697 <br />SIGNED( iv TITLE /t / V I VL `K DATE <br />9�4' <br />CF)�Eo4r . <br />19 ?�?2 <br />/At c <br />MFS <br />R �- <br />T <br />DEPARTMENT USE ONLY <br />Application Accepted By �%Zl.� Date S 17 as Area y/9y Employee ID# All <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Date 21 S��-j`���Z�L WAIVER Received <br />Soil Boring Inspection By Date C nstructed Well De th ft <br />COMMENTS ameA� 1 Y114 Ji � e L S <br />PE <br />Codes <br />SC i Received Chec <br />Info B <br />Amount DatePermit/ Invoice # Well ID# <br />Remitted Se 'ce Re ue t <br />381 <br />so <br />7 <br />EHD 4306 6/11/2019 <br />WELL /PUMP PERMIT <br />