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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />JOB ADDRESS G TJ _ CITYIIIZIP —1 V <br />CROSS STREET 40 O � KA 75O� APN 3—L•-0 /PARCEL SIZE &I LAND USE APPLIICCATI�O'N{# L� fI� <br />OWNER NAME - oe a ..tt ql Q0./ C'` PHONE �O i • �J — ' L <br />OWNER ADDRESS 3 oaZ C ) V ` CrrY/STATrJZIP <br />CONTRACTOR %1 f ffKO�� ,i1{• 1 t 1 C • PHONE —1 <br />CONTRACTOR ADDRESS Lcx-4 .W CrtY/STATEJZIPn-Dd es -t -o. C a 953 <br />SUBCDNTRACTORICONSULTANT <br />SUBCONTRACTORICONSULTANT ADDRESS <br />``, <br />LICENSE / -57 C-61 <br />BILLING PARTY: OWNER <br />D-09 <br />Other <br />PHONE <br />CrrYQ/STATEIZP <br />NUMBER 2—`O • EXPIRATION DATE 2'2�f <br />+ <br />SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private rrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water Sy em <br />If different from Owner Water System <br />Contact Name or Phone Number <br />TYPE OF WORKNew Well Replacement Well D Well AlterationlModification Other <br />. Monitoring Well(s) # of wells D Soil Boring(s) n °f bO""qs Geotechnical u of bodngs <br />Out -Of -Service Well ❑ Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement D Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger L Cable Tool Push Point Other <br />Proposed Well Depth N0101, ft Excavation 11a— in diameter IOpen Bottom xGravel Pack/Gravel Size Wo (y in diameter <br />Condu Casing ;2. in diameter / Conductor Casing Depth ft <br />Well Casing Diameteerr�.,,b n ;bickness/Gauge/ASTM Schad ��<SteeI Plastic Stainless St el - Other <br />Grout Seal Depth7x50 It%N t Cement (94 /b baV5-10 gal wgbr) `� Sand Cement t sack mixrl gal water <br />Bentorlite.(20% solids)) r'ili50 COQ C„Ct1f en <br />Grout Placement Method &Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Xump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in 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 AM IN COMPLIANCE NITH ALL <br />WORKERS COMPENSATION LAWS. <br />DEPARTMENT USE ONLY <br />Application Accepted By f—! L - Date ') .%.>vl Area S Employee ID# <br />Grout Inspection By Dat. 1 SPECIAL Well Permit <br />Pump Inspection By <br />Date <br />WAIVER Received <br />Soil Boring Insp ion By Date Constructed Well Depth ft <br />COMMENTS rG Ci L' <br />EHD 43-06 6/112019 WELL /PUMP PERMIT <br />IENT <br />IVE® <br />2021 <br />COUNTY <br />ENTAL <br />RTMENT <br />