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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 />1MUnr-MhI-UNUAI3LE PER MIT <br />Ov.Or /end <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 40 <br />(/ y� !/ <br />i v� 1 Q /' ce <br />�/WWWW.S <br />, / <br />A-.4, CITY/ZIP <br />Z-0-610 <br />CROSS STREET 64 C <br />/(�V <br />�6n (may/ APN <br />PARCEL SIZE 3�_ <br />LAND USE # <br />OWNER NAME <br />To L /Yf /� <br />/APPLICATION <br />PHONE 61K.3 .3 L? <br />OWNER ADDRESS �//'(L <br />CITY/STATE/ZIP <br />21's <br />CONTRACTOR <br />�C `��Qss %LLCi( <br />� <br />PHONEy�2 <br />CONTRACTOR ADDRESS <br />/� <br />,s/J7� <br />CITY/STATE/ZIP �WC//,iK`�'� <br />SUBCONTRACTOR/CONSULTANT 7n0 <br />g S "YM <br />PHONE -s 7-77-13 I L.p <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CI <br />LICENSE P C-57 <br />❑ C-61 ElD-09 11Other <br />7/STATE/ZIP <br />ITTY <br />NUMBER 3 ! s <br />EXPIRATION DATE ♦�� Z? <br />BILLING PARTY: <br />❑ OWNER ^ONTRACTOR <br />❑ SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE omestic/Private ❑ 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 ' ' Iew Well Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />>14lew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casino <br />WELL CONSTRUCTION <br />Drilling Method>!�`Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well DepthW ft Excavation 11- 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 � a 11 Steel Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth a) ft ❑ Neat Cement (94 /b bag/5-10 gal water) XSand Cement AC). 3 sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method -KPumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By -? Driller ❑ Pump Contractor ❑ Other. <br />❑ Concrete Pedestal [I Dimensions: Width I ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP <SUbmersible❑ Turbine ❑ Other HP __2` 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 I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMV 48 HOUR ADVANCE NOTICE REQUIRED FOR/INSPECTIONS - PLEASE CALL (209)9953-7697 <br />SIGNED TITLE e6li rA DATE IF— 7-j —w <br />T <br />m <br />D <br />0 <br />0 <br />m <br />m <br />AppNtion Accepted By "� <br />grout Inspection By <br />F•mp Inspection By <br />Soil Bcing Inspection By <br />COMMEI'+S <br />PE ':kC <br />Codes Ir:o <br />X137 iF� <br />N 3G I <br />Ll 39 9 <br />u-�80 OS <br />EHD 43-06 6/11/2019 <br />Date rbobl Area l C Employee ID# 7y <br />Date ❑ SPECIAL Well Permit <br />Date ❑ WAIVER Received <br />Date <br />Constructed Well Depth <br />ft <br />WELL /PUMP PERMIT <br />