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WELL/PUMP PERMIT i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> — �� g CITY/ZIP <br /> EXPIRES 1 YEAR FROM DATE ISSUED <br /> _ <br /> NON-REFUNDABLE PERMIT WW_W.S OV.Or /ehd E _ <br /> JOB ADDRESS l ,• /J�3 �f3'z J�2 m <br /> CROSS STREET_ 1�e _A P N [PARCEL SIZE _LAND USE APPLICATION# p <br /> m <br /> ,I m <br /> OWNER NAME / ram / / j7 ONE TO 9, q-/ .-noito�.� _- - - - PH_/ <br /> OWNER ADDRESS .—�zeeGe 0'6-k �'.aj- CITY/STATE/ZIP <br /> 117, <br /> CONTRACTOR _ ���'jY) //d_fH1 �/7�i - _- PHONE <br /> CONTRACTOR ADDRESS (� /�jp� L `� Z7 CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE XC-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 7 EXPIRATION DATE_ _3�� 2 Z <br /> BILLING PARTY: OWNER .'CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:X(General Mineral/Coliform Bacteria(4391)4 Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> 11 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 /> El Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> I] New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method r1CMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> i <br /> Proposed Well Depth �1 ft Excavation /z 7V in diameter ❑ Open Bottom Y—ravel Pack/Gravel Size_ in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter (& in Thickness/Gauge/ASTM Sched !" t/ ❑ Steel CPlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth— ft ❑ Neat Cement(94 lb bag/5-10 gal water) XSand Cement 0- 5 sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method k Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By 9.Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width._ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> rPuMP Submersible❑ Turbine ❑ Other HP� Pump Set _.ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 COMPENSAT N LAWS. <br /> MINIMUM H R ADVANCE N E REQUIRED FOR INSPECTIONS-PL SE CALL(209)963-7697 <br /> SIGNED TITLE � / DATE /Q�2'Z�ZO <br /> it <br /> — I <br /> I <br /> I <br /> t (; U <br /> :101RONIAET, <br /> LH <br /> w - <br /> / DEPARTMENT USE ONLY Application Accepted By C—� Li Date a /;?o�0'Rv Area Employee ID# DA <br /> Grout Inspection By _ _ _- Date �!hZ,�Z SPECIAL Well Permit <br /> Pump Inspection By Date�v t�v WAIVER Received <br /> Soil Boring Inspection By _ Date Constructed Well Depth 00 ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Permit/Codes Info B Cash Remitted Date Service Re uest# Invoice# Well ID# <br /> ar v-- - 1sa io +2 32 Z <br /> 43 18� 'L q. co -+2.2o WP <br /> 43q _ 2 15-0 t2 4.kQ 0 <br /> EHD 43.06 6/11/2019 <br /> WELLlPUMP PERMIT <br />