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f' <br /> WELUPUMP PERMIT <br /> y SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT wwW.S ov.or /ehd }-�/EEX�PJI�R/E�S/I YEAR FROM DATE ISSUED <br /> JOB ADDRESS S• CITYI/L-IP7 ►//t A&t'ft�f7l/�l 6y <br /> CROSS STREET Eleven � n A(`PN�-�+v s+ �U PARCEL SIZE�� l LAND US('EA/PPLICATION# <br /> OWNER NAME is 1 e 1�nQcr C'q,\ <br /> OWNER ADDRESS I T'V CT/STATE21PCAPVH�ONL�I^I'.�".v[Q 7— 71B7g�'Ml/�l] <br /> ? <br /> CONTRACTOR �aS+� y�NDnG Lj- PHONE11 I - -D1 <br /> CONTRACTOR ADDRESS U&X I4_ 6 CI Y/STATEILP1p'\1W <br /> e+ <br /> SUBCONTRACTORICONSULTANT P7 PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITYISTATE/ZJP <br /> LICENSE A C-57 C-61 D-09 Other NUMBER 04 � EXPIRATION DATE <br /> BILLING PARTY: OWNER CONTRACTOR SU13CONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:kGeneral Mineral/Coliform Bacteria(4391)ADibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/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 X New 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 /> New Pump Pump 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 ��JDD ft Excavation in diameter Open Bottom k Gravel Pack/Gravel Size in diameter <br /> 'onduct�r``r—ing in diameter / Conductor Casing Depth ft <br /> Well Casing u smeter rO .' Thickness/Gauge/ASTM Sche&bRaj Steel XPlastic Stainless Steel Other <br /> sOLLGrout Seal Depth QRtill ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mixf7 gal water <br /> IJ ]PCAOw XBentonite(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 Length It 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI=ADVANCE <br /> =ADVANCE NOTICE REQUIRED FOR IN§PE(C,T_I/ONS-PLEASE CALL(209)95r3-77 97 <br /> SIGNED n\/ Y \/ TITLE (�l�'V/ DATE71 82 <br /> �l <br /> let <br /> 71 <br /> 8 <br /> alaisI A <br /> 16 <br /> Lro oc,,H ��?1 <br /> Ae� Ori (lei QO3 EPARTMENT USE ONLY t+"is�l� CC J g�lt� pFp�N�iyn, <br /> AppplicaGon A pled By A AL�� Date 7 1 1111 ��ff Area Employee ID# T/hFh <br /> Grout Inspection By .�►-�.�� Date (1 '5 � SPECIAL Well Permit T <br /> Pump Inspection By A• Date 1 1.`TStll WAIVER Received <br /> Soil Boring Irlspection By D e $ tru ted Well Depth ft I, <br /> il <br /> COMMENTSfiaM �eYI' O 0 J r- ��yt(� b <br /> • Itl.+rfo r <br /> PE SC Received C ac Amount Permit/ ' <br /> Codes Info B ash Remitted Date 6jfk1que t# Invoice# ell ID# <br /> b /Jrq�zozl <br /> le <br /> rD <br /> 4 o <br /> EHD43-06 6111/2019 WELL/PUMP PERMIT <br />