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t <br /> 1P <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HA7EI-TON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT WWW.sjgoV—.OAr /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> LAI <br /> JOB ADDRESS rr 13-1 �•1,G �/f rY7 CITY21P�1�/i{,(/moi( ��f'V"l [ig <br /> CROSS STREET '/�r'�V6YI}I1 A('PN� ISO /"p PARCEL SQE�LAND UUs(EAPPLICATIONII �j-� _ }%0 <br /> OWNER NAME v1,I�y I� K�Ct\ 'T� _ PH�O- 10 <br /> D I /-y�)/�/qpr�/� u+ <br /> OWNER ADDRESS /''� I V CITY/STATEIZIP ' ,y t^s" �j�/►'J�"fM� ' <br /> CONTRACTOR ( as at-q- V•�V'WII�(�{(JIr 11 b iy PHONE 1.^ � /_'(1 rnl. <br /> CONTRACTOR ADDRESS P lJ&1 5 l`CK, l�Jt- CITYISTATE/Z P VI,I -, , 12(67 <br /> SUBCONTRACTOR/CONSULTANT ��►'] PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 D-09 Other NUMBER ExPIRATION DATE <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:kGeneral Mineral/Coliform Bacteria(4391) ibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If dnerem from Owner Water System Nano Costed Name or Phone Number <br /> TYPE OF WORK /�New Well Replacement Well Well AlterationlModificalion Other <br /> Monitoring Well(s) If of wells Soil Boring(s) 0 of borings Geotechnical x 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 /> WELLCONSTRUCTION <br /> Drilling Method-�C Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth :310t) R Excavation a in diameter Open Bottom )(Gravel Pack/Gravel Size in diameter <br /> Conduct r Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter in Thidmess/Gauge/ASTM Sche&�\Q1) Steel xPlastic Stainless Steel Other <br /> Grout Seat Depth�;ZW _ft Neat Cement(94 lb Dag/5-10 gal wafer) Sand Cement sack mix/7 gal water <br /> 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_ft Length H Thick in Christy Box Stow Pipe <br /> Py,lep 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 17���\HR/ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7 97 <br /> SIGNED n�./ Y \/ _ T. Def►l Imo,' DATE <br /> 11 L 11 1111 11 111 1 <br /> it <br /> 4 <br /> ��N81�21 <br /> DEPARTMENT USE ONLY THpFpM�cN�Uryry <br /> Application <br /> Grout Inspection By A• Date�����ted By Date Area SPECIAL WC I Pef1T11t KIT MT <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring I pection By D' a Constructed Well Depth R <br /> COMMENTS ATnump Peed is reou rte,! of syn p_ <br /> PE SC Receivedec Amount Data PermiU Invoice# Well ID# <br /> Codes Info B ash RemiRsd ce ue t# <br /> 43f k, <br /> 41A T r0 <br /> CH043-06 W11r2019 - _� -- --_ -- VIEL RUMP PERMIT <br />