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t r <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT �M y� www.s-iqov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSt20974- M O I r ! / CITY21 In <br /> C' t r),ba- a� r <br /> CROSS STREET v�� e. AP PARCEL SIZE �J LAND USE APP CATION# A <br /> r m <br /> OWNER NAME a PHO'N'A1 �p�� ✓^�l�v� H <br /> OWNER ADDRESS W tet. CITY/STATEPZIP Ifj t 11/11111!I 1li(/{/�� "I S�t=JT1(J <br /> CONTRACTOR `^.�J/Y�l���.y^�y�l,L( (1(�/r� PHON fc/t ' V) <br /> CONTRACTOR ADDRESS r V l>< 144(a CITYISTATE/ZIP�LI-�✓•/ \—,�Q� <br /> SUBCONTRACTOR/CONSULTANT A PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STA /ZIP <br /> LICENSE /�:-57 C-61 D-09 Other NUMBER EXPIRATION DA <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:XGeneral Mineral/Coliform Bacteria(4391)kDibromochloropropane(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 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 Rota Air Rotary Auge Cable Tool Push Point Other <br /> Proposed Well Depth it Excavation ly=l in diameter Op�L1 lotto,;Ix Gravel Pack/Gravel Size in diameter <br /> Conduc asing in diameter / Conductor Casing Dept 0+-1 ft <br /> Well Casing Diameter n Thickness/Gauge/ASTM Schad Steel x Plastic Stainless Steel Other <br /> Grout Seal `Depth it Neat Cement(94 111 bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> hrBentonite(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 ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set it 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 COMPENSATkON LAWS. <br /> MINIMU 48 A NC E REQUIRED FOR INSO�C�TIQNy�PLEASE CALL(2 9 9 3- <br /> 1 SIGNED TITLE ]u 1 I"(/�/ DATE _ <br /> RF YMFN <br /> U! <br /> qQ�?g ?0471 <br /> Vo � Y <br /> T�N' <br /> DEPARTMENT USE ONLY Q 41 <br /> qr <br /> Application Accepted By < /` <�` Date / Area `� Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS Plt�ej�t 1 �p�Qas,e <br /> PE SC Received ec Amount Dat Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Re uest# <br /> 346 j o b <br /> 4 <br /> 476 <br /> EHD 43-06 6111/2019 WELL/PUMP PERMIT <br />