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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 WWW.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS `� - <br /> ' �' CITY/ZIP -1`� <br /> m <br /> CROSS STREET APN O <br /> PARCEL SIZE � LAND USE APPLICATION# o <br /> my//�RL�Jo PHON � A\ bciOWNER NAME <br /> OWNER ADDRESS �L. CITY/STATE/ZIP ,/� <br /> CONTRACTOR <br /> � <br /> /PHONE 3 / Z <br /> �L / 3 <br /> CONTRACTOR ADDRESS Py`�C;-/ f 7 i CITY/STATE/ZIP bee, 2a,x��e <br /> SUBCONTRACTOR/CONSULTANT PHONE J� <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE Ow-9-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 3','�2�1 EXPIRATION DATE 6_--2 <br /> BILLING PARTY: I OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:yGeneral Mineral/Coliform Bacteria (4391),4Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE omestic/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 ,�55New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> Li Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings LiGeotechnical #of borings <br /> 11 Out-Of-Service Well Ll Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodXUud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth >CP ft Excavation in diameter ❑ Open Bottom Gravel Pack/Gravel Size_in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diametertx'� in Thickness/Gauge/ASTM SchedZ22 ❑ Steel e-- lastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth L(TL' ft ❑ Neat Cement(94/b bag/5-10 gal water) \7.8and Cement�40-�3 sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other l <br /> Grout Placement Method'�KPumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal []Dimensions:Width ft Length=ft Thick * in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ubmersible❑ Turbine Li 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 /> MINIM M 48 HOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7!697 <br /> SIGNED M 71 TITLE 0441`—'_ DATE S'— tD `- y <br /> IV 0 <br /> NT <br /> O <br /> V L <br /> TN MAm 711- <br /> U <br /> T <br /> IV61 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID# <br /> DA <br /> Grout <br /> Inspection By Date t t y ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS V-jeii ZIR remAlk) SC/v' cjysJ I°s�<.il�; Sf ��C� Well <br /> "f� � � 411 161 I• <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By_ ash Remitted Service Request# <br /> 2W 9611 L�U 4q <br /> '�o Z ?- <br /> 3(v 1 IS-0 519 <br /> L13lL ¢-76 t / <br />,EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />