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Z 'S1 <br /> ( WELL/PUMP PERMIT -e- r /- P FPS �t <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT W1NW'S Ov.or hd EXPIRES 1 YEAR FROM DATE ISSUED <br /> • �� <br /> JOBA DDRESS rn <br /> /� CITY2IP y <br /> CROSS STREET APN ,r, Li.� v"'1 j^ m <br /> PARCEL SRE LAND USE APPLICATION# S U D <br /> 0 <br /> o <br /> TOWNER NAME � <br /> PHONE w <br /> TOWNER ADDRESS 5 �•' <br /> ITYISTATEIZIP <br /> CONTRACTOR <br /> PHONE �� ^` <br /> CONTRACTOR ADDRESS �fl <br /> M CITY/STATEZP <br /> SUBCONTRACTOR/CONSULTANT / C^ ,0i� ��r ��,�/J <br /> PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS <br /> CI/TY//$TATEV/7Jp <br /> LICENSE -C-57 C-61 D-09 -1 Other NUMBER l/ l: �- I � ,7 r ,. <br /> _CONT ) <br /> TE f <br /> BEXPIRATION DA <br /> BILLING PARTY; _OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(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 <br /> Contact Name or Phone Number <br /> TYPE OF WORK eW Well 'X Replacement Well Well Alteration/Modification <br /> Other <br /> Monitoring Well(S) #of Wells SOiI Boring(s) M of ba 9s <br /> Geotechnical 4 of borings <br /> Out-Of-Sere ce Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> ew Pump Pum2 Replacement Pump Re air <br /> WELL CON_STRuc77oN :�Raise Well Casin <br /> Orfiling Method �Mud Rotary Air Rotary _Auger -Cable Tool Push Point Other <br /> Proposed Well Depth Ste% ft Excavation_� <br /> 1 I �-In diameter Open Bottom :*Gravel Pack/Gravel Size <br /> Conductor Casing n diameter / Conductor Casing Depth_it <br /> in diameter <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched v <br /> rout Seal Depth G ( �C: Steel •7PIastic - Stainless Steel Other <br /> P ft Neat Cement 94 1b bag75-10 gal water) Sand Cement <br /> .1 Bentonite(20% lids) _:Other sack mixt)gal water <br /> Grout Placement Method C•Pumped _Free Fall ___ Other <br /> Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller .;�:Pump Contractor _ Other <br /> Concrete Pedestal t7Dlmensions:Width_t it Length Ct_R Thick c in -Christy Box .-Stove Pipe <br /> uMa Submersible_ Turbine . Other HP <br /> Pump Se!_f 46 1t 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 /> 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 COMPEN ATION LAWS. <br /> a liVlr 43 HOU ADVANCE NOTICE REQUIRED FOR INS ECPLE.ASE CALL(209)953-7697 <br /> SIGNED <br /> TITLE <br /> DATE <br /> I• <br /> NT <br /> ED <br /> e v <br /> srood� <br /> L 2021 <br /> OUNTY <br /> N TAL <br /> TMENT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By G- Date )J /L1 d) Areal� <br /> Grout Inspection By t.t � Employee ID' i 'Ii �• �: <br /> Date SPECIAL Well Permit <br /> Pump Inspection By Date Com^/ '-Z <br /> WAIVER Received <br /> Soil Boring Inspection By Date <br /> COMMENTS Constructed Well Depth <br /> If <br /> PE Sc Received Check#/ Amount <br /> Re I Permit/ <br /> Codes Info Cash Rted ate Invoice# <br /> I- IF � Service Request, Well ID# <br /> L ell !s-D I tr <br /> 3� 7Q) lit ,/ <br /> 3 <br /> EHO43„+3 6/11/2019 <br /> VILL"LIMP PERMIT <br />