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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205.6292(209)468.1420 <br /> NON-REFUNDABLE PERMIT WWW.sjgov.orP1eh4EXPIRES 1 YEA FROM DATE ISSUED <br /> L. <br /> JOB ADDRESS G _ c-1-P '•-. � n7 <br /> CROSS STREET APN PARCEL SIZE ' D <br /> LAND USE APPLIC TION# g <br /> ,f _ m <br /> OWNER NAME 2 `�I 7 ��1 'p1(.,j.,, PHONE t H <br /> OWNER ADDRESS /�3a."J C) V�V'�CQI�I�I `r I L VN CITY/STATEZP - A/ <br /> CONTRACTOR ( 'C'kt C' V(IJt��( PHONE �I/��r,I, <br /> CONTRACTOR ADDRESS V v 1� L, CITYISTA.F= AK F`A <br /> SUBCONTRACTORICONSULTANT V 1 CA— PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE2 p <br /> LICENSE -/G57 U C-61 i.D-09 Other NUMBER (PIRATION DATE <br /> BILLING PARITY:' I-:OWNER ]CONTRACTOR :1 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) .Dibromochloroprcpane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private I7 Vrigation/Agricultural D Industrial U�WaterCluafity Monitoring 0 Soil Sampling/Characterization <br /> n Public Water System <br /> R different from Ower: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well t I Replacement Well D Well ARerationlModiRcatlon i'i,Other <br /> C Mon Boring Wells) #of wells 0 Soil Boring(s) 0 o bonngs C Geotechnical #afbcnngs <br /> 0 Out-Of-Service Well D Out-Of-Service Well Renewal LI Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement =Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method'�Mud Rotary i.I Air Rotary Auger - Cable Tool 'Push Point D Other <br /> Proposed Well Depth R Excavation��in diameter ❑Open Bottom (Gravel Pack/Gravel Size in diameter <br /> Condu asmg in diameter I Conductor Casing Depth It <br /> Well Casing Diame er in ThicknesslGauge/ASTM Schede D Steel (Plastic ^Stainless Steel L'Other <br /> Grout Seat Depth R ❑Neat Cement(94 to beg/5-10 gal water) _Sand Cement sack mix/7 gal water <br /> �-'gentonite(20%solids) D Other <br /> Grout Placement Method umped D Free Fall E Other :'Retardant/Accelerator(name) <br /> PSTA Insla!led By D Driller ump Contractor - Other <br /> 17 Concrete Pedestal I701menslons.Width R Length R Thick in D Christy Box [i Stove Plpe <br /> IEM 0 Submersiblei:l Turbine :l Other HP Pump Set R Standing Water Level R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQ UIN 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 CO SAT111 N LAWS. <br /> ,; FAD/j�f�UT\E NOTICE REQUIRED FOR INSPEt71pfy5-PLEASE CALL(209)953.7 97 <br /> SIGNED G '/ v TITLE 1' 111DATE V <br /> IT MENT <br /> FECEIVED <br /> EC 10 2020 <br /> SO H OAQUIN COUNTY <br /> RONMENTAL <br /> 11 Eill LTH DEPARTMENT <br /> )) Date DEPARTMENT USE ONLY <br /> Application Accepted By �L <br /> Z 44b <br /> Area S / Employee 109 L--7-1 <br /> Grout Inspection By _ Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Son Boring Inspection By Date Constructed Well Depth N <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit) Invoice# Well IDD <br /> Codes Info B Cash RemittedService Request* <br /> 3rd I /, d LIO L L <br /> �3r Is o" <br /> X13 70 L•ID'LU <br /> EMD 4346 6111/2019 WELL(PUMP PERMT <br />