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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209) 4683420 <br />NON-REFUNDABLE P�E7R2MITi www.sjqo.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 1 J 1 \ �G „n r; 14, Nit ca <br />CITY/ZIP Lc CL �I 2-4 O m <br />CROSS STREET�} l > . / <br />_�- Asc ."\ ,,.y ApN _6 63 L Al / .Z PARCEL SIZE _LAND USE APPLICATION # O <br />0 <br />OWNER NAME r7 :✓'i Li it 7 <br />2 \ _ PHONE'%�_</ j <br />OWNER ADDRESS i��ll3 Lc�Ll r.L..sv- <br />` r - CRY/STATE/ZW t C( -'Ti ` \.� C, 7r <br />CONTRACTOR /}(PHONE' <br />CONTRACTOR ADDRESS I / AX CITY/STATE/ZIP J �l fi �! YYr1•-+ /`T] �'� l.%.l'i <br />LICENSE rrC-57 <br />BILLING PARTY: <br />.TANT <br />_TANT ADDRESS <br />F' C-61 - D-09 - Other <br />F OWNER - CONTRACTOR <br />PHONE <br />CrrrrY/STATE/ZIP JP �7 <br />NUMBER &VY �`L EXPIRATION DATE I 3`' <br />� SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: J General Mineral/Coliform Ra Maria id4011 i n,ti.....,....r.l..._..______ - .. <br />_--- _.._1.__.� ..,.,�.,���w,n.nvPwPane tyoui)_ Arsenic(43y3) <br />INTENDED USE � Domestic/Private I Irrigation/Agdcultural r- Industrial r- Water Quality Monitoring F Soil Sampling/Characterization <br />7 Public Water System <br />If dlRerant from Owner: Wats Sy m Neme Contact Nam. or Phone Number <br />TYPE OF WORK I New Well - Replacement Well ell Alteration/Modification r Other <br />Monitoring Well(s) # of wells -)Soil Bodng(s) # of borings -7 Geotechnical <br />-1 Out -Of -Service Wee -1 Out -Of -Service Well Renewal - Cross -Connection Repair <br />New Pump ump Replacement i Pump Repair i Raise Well Casino <br /># of borings <br />Drilling Method J Mud Ro.ta�ry. -j Air Rotary L Auger L'�able To Push�Pq�ah _ Other <br />Proposed Well Depth — A) ft Excavation in diameter Li Open Bottom Gravel Pack/Gravel Size <br />in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 16 in Thickness/Gauge/ASTM Sched eel - Plastic -1Stainless Steel r Other <br />Grout Seal Depth ft i Neat Cement (941b bag/5.10 gal water) - Sand Cement <br />-1Bentonite (20 % solids) -1Other sack mix17 gal water <br />Grout Placement Method L Pumped L Free Fall L Other L Retardant /Accelerator (name) <br />IPEDESTAL Installed By J Driller J Pump Contractor L Other <br />� Concrete Pedestal LDlmenslons• Width ft Length ft Thick n L Christy Box j Stove <br />ruMP iol Submersible -1 Turbine -1 Otheru <br />HP P mp 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 />I <br />SIGNED -� IN4I'll 4� It,(JP ti,/ANCE NOTICE REOMRED sC)RAINSh'ECTlONS -- ;LEASE CALL (209) 9-Y-769-/ i 7697 <br />TITLE .t V \ /� V !-Y �lZ DATE <br />IYWNT <br />mel A t) <br />4 2020 <br />"wv'N COUNTY <br />tONMENTAL <br />DEPARTMENT <br />DEPARTMENT USE N L Y <br />Application Accepted B <!=�-z' •- j- D f <br />By Date /� �t�+1 �' Area � / / Employee IDkJ �+ <br />Grout Inspection ByDate SPECIAL Well Permit <br />Pump Inspection By Date Tl� St `ZZ -1 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth f <br />COMMENTS ;:.) i>?r % W J It ft <br />, . t Fi <br />- 1a - p <br />n 7 <br />n PG }ti <br />I <br />I . %. F�� <br />I-- ^ O <br />PE SC Received AS � <br />mount Pennitt �J <br />Col <br />Info <br />B <br />Data <br />Cash Remitted <br />Service Re uest # Invoice # Well ID# <br />tN ov <br />EHO43-p6 6/11/2Q19 <br />��' 22q -7(n ( /J w�` ` V�ELL/PUMP PERM <br />IT V 1M. <br />