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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT) CALL 209 /9r53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ! / :��N1 Ile I ev/� CITY/ZIP m <br /> / /� L 2-3D <br /> CROSS STREET � x��� APN /c/ �� 9 /O "—PARCEL PARCEL SIZE � �LAND USE APPLICATION#[ A <br /> OWNER NAME 't"L [-�� ( //C//� /1� C� PHONE �Cj /(J J ' cn <br /> OWNER ADDRESS j�/4.o: �� CITY/STATE/ZIP <br /> CONTRACTOR X1i7l/\ 'ill'42f 1,LL 14 PHONE <br /> CONTRACTOR ADDRESS �jC �� CITY/STATE/ZIP /�nt'J /✓!��{(/((E� <br /> SUBCONTRACTOR ��6 ��1 ( 7�.)_r� ib�i1 PHONE ] L <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> -"7 ' <br /> LICENSE ��f-57 I I C-61 ❑ D-09 I I Other NUMBER N� i-3 L EXPIRATION DATE (' - �J <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE 'i Domestic/Private Irrigation/Agricultural I Industrial Water Quality Monitoring ' Soil Sampling/Characterization <br /> L' Public Water System ®� _ <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ,>P14ew Well Li Replacement Well IJ Well Alteration/Modification Other VGA <br /> pf <br /> n Monitoring Well(s) #of wells I I Soil Boring #of borings s) I I Geotechnical borings(�0O -Of-Service Well LI Out-Of-Service Well Renewal 1 Cross-Connection Repair SAN U 9 2019 <br /> , New PumpPumpReplacement I' PumpRepair � Raise Well Casing �Oq <br /> WLL <br /> Drill ng Method CONSTRUCTION ud Rotary E Air Rotary I I Auger Cable Tool ❑ Push Point I I Other R�LTH EPARTMMzr_ <br /> Proposed Well Depth��ft Excavation !�� in diameter LI Open Bottom L!r,�ravel Pack/Gravel Size in diameter <br /> u ConductX Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched �� L-1 Steel �'lastic I1 Stainless$eel Cl Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ' and Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method-.,,—Pumped ❑ Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By 'i440riller I I Pump Contractor I I Other <br /> [I Concrete Pedestal I IDimensions:Width ft Length ft Thick in I Christy Box I I Stove Pipe <br /> PUMP J('f�ubnnersiblel I Turbine I I 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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-76y97 l C <br /> SIGNED ��- TITLE l Jl 1J� > � DATE a / <br /> C <br /> DE.'PARTMENT SE ONLY <br /> Application Accepted By I Date O Area Employee ID# <br /> Grout Inspection By Date 2� ❑ 'SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received 16hecW Amount Date Permit/ Invoice# Well ID# <br /> Codes Inrfoo, BV Remitted Service Request# <br /> Yv 9 <br /> EHD 43-06 8101116 WELL/PUMP PERMIT <br />