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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMITQ <br /> ���St t p .s ov.of /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS r,23403 ` 1 -Dj "(�`, c,Ty�l/rpkj <br /> CROSS STREET IJ�J�(-T"I `JTn, {��( /ct APNZq•'jJI 0 II yry i- <br /> PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME 1 Ii1 G�.-C/\[/<• 'NM2a k w y-1 PHON <br /> OWNER ADDRESS `/ t'•' CITY/STATEIZIP O <br /> Risk <br /> CONTRACTOR t/✓IJ! `C II'/�V�C/1.t, t"f (� "^y PHONE "f�V'! I'` iD 'v'O� <br /> CONTRACTOR ADDRESS \J � "-[�(V/ CITY/STATE/L �,1/1 P I Y k Y�& -LJ:?,(x;-) <br /> SUBCONTRACTOR/CONSULTANT I-A PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATEIZIP <br /> LICENSE )CC-57 ;C-61 D-09 ❑Other NUMBER a EXPIRATON DATE `) <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING j-General Mineral/coliform Bacteria(4391)XDibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ftomestictPrhate _!Irrigation/Agdcultural a Industrial D 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 •.clew Well X Replacement Well J Well Alteration/Modification L Other <br /> C Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #or borings <br /> F Out-Of-Service Well F II Out-Of-Service Well Renewal =Cross-Connection Repair <br /> L New Pump ❑Pump Replacement U Pump Repair _Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method KMud Roc Air Rotary I7 Auger ❑Cable Tool C Push Point - Other <br /> Proposed Well Depthft Excavation Z in diameter `J Open Bottom XGravel Pack/Gravel Size in diameter <br /> J Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schecf D [.'Steel Plastic 0 Stainless Steel -Other <br /> Grout Seal (Depth ft 7 Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> 1(4entonite(20%solids) D Other <br /> Grout Placement Method umped ❑Free Fall C Other i Retardant/Accelerator(name) <br /> PEDESTAL Installed By i'Driller XFump Contractor 1.) Other <br /> D Concrete Pedestal uDimenstons:Width It Length It Thick _ in 7 Christy Box L Stove Pipe <br /> PUMP C SubmersibleD Turbine a Other HP Pump Set it Standing Water Level — it <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 /> MINI 4 U DVANCE NOTICE REQUIRED FO'Fj II\NSSP (((+++{{{TI��.ON PLEASE CALL(209)953-7697 SIGNED TITLE ►�J �� DATE2:21-1U <br /> pq YM <br /> FCFj�NT <br /> o UI/NI�Vcouf <br /> 0 <br /> H I 19-H+H- <br /> DEPARTMENT USE N L Y _ pAR 0- <br /> Date Application Accepted B v 7 r� Lo J C{1 C �( <br /> PP P y Date Area I Employee ID# JI <br /> Grout Inspection By I Date 2, SPECIAL Well Permit <br /> Pump Inspection By Date 7 WAIVER Received <br /> Soil Boring Inspecti n By Date Construe}ed Well Depth ft / <br /> COMMENTS vie, / S bG r (A �lo`r(�t / rtiI pI/y <br /> We I IQ b rn cl,I jZPA'jSJ`jI1ejL4,0111 <br /> PE SC Received Check#/ Amount Date PermiU Invoice# Well ID# <br /> Codes Info B Ca Remitted Re nest# <br /> 936E v a70 Z S rvice 0 <br /> 43(1;1 a)so <br /> 43( 7b <br /> EHD 43-06 6/112019 <br /> I J /t///y5s-ns- WELL/PUNP PERMIT <br />