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DU <br />`� 1-7 `� WELL/PUMP PERMIT k <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE RERMIT www.sl9ov.oTq/ehd n . EXPIRES 1 YRAR FRWn,DATE ISSUED <br />I" I V L-0 0 LR ( /Lot I �- qm D L C� 9 t, Z Z�� <br />SC Rec iv d Check#/ Amount Date Permitt Invoice # Well ID# <br />Info h Remitted Service Re uest # <br />b� <br />JOB ADDRESS CITY21P p <br />CROSS STREET ' 1 )YI S�) PN O �'y PARCEL SIZE CJ LAND US # <br />b�D <br />P LION <br />p <br />- <br />OWNER NAME G w rc e 5 <br />m <br />/4�,,J, /IPHONE <br />1 <br />() C <br />rn, <br />OWNER ADDRESS V V TPIaP <br />(/CITY/S <br />' l <br />Pit <br />CONTRACTOR It itrk) o PHONE V <br />/ <br />( <br />CONTRACTOR ADDRESS l CITY/STATE/L <br />% <br />SUBCONTRACTOR/CONSULTANT ` PHONE <br />('(/fit <br />SUBCONTRACTOR/CONSULTANT ADDRES I, ` h ISTATEMPn <br />LICENSE C-57 /� ,C-61 D-09 Other NU -EXPIRATION DAT <br />v <br />BILLING PARTY: .� <br />BILLING OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WE S PLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE ADomestictPrivate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water System Name Contact Name a Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />l V <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings Geotechnical # of borings <br />Out-Of-Servi Viell Out -Of -Service Well Renewal Cross -Connection Repair <br />_ New Pump um Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <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 wafer) Sand Cement sack mixl7 gal water <br />A <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 Dimensions: Width It Le h ft Thic in Christy Box St ve 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 r1 <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 />W <br />Application Accepted By .ZDate Area �9 "'/ Employee,D# F R <br />Grout Inspection By Date SPECIAL WBII Permit <br />Pump Inspection ByQ.A eAt= t, Date -21/ 3am- WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC Rec iv d Check#/ Amount Date Permitt Invoice # Well ID# <br />Info h Remitted Service Re uest # <br />b� <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />J <br />J <br />J <br />YMENT- <br />CEIVED <br />10 2021 <br />OAQUIN COUNTY <br />VIRONMENTAL <br />TH DEPARTMENT <br />