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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,P MITOV.OP /ehd —/-��, /EXXPIRES 1 YEAR FROM DATE <br /> DATE ISSUED N <br /> ram/(( �/� CITY/ IP r"ti' [ fl� ��'� 6 -7 m <br /> JOB ADDRESS ` r Y�'0 i 6 ter D <br /> t r 4, 7 <br /> f�e'(-4r}�UY APN T - - (PC) PARCEL SIZE LAND USE APPLICATION# A <br /> CROSS STREET m <br /> t) � �c� c y <br /> ONE <br /> OWNER NAME d� f ��7 -7 <br /> ()Y r 1 1f CITY/STATE/ZIP /! t✓l a <br /> OWNER ADDRESS I �� � C/ <br /> /�•''• e rJ HONE 4� <br /> CONTRACTOR '�f ��C �� �� 'tj't � <br /> Tv If I'l L +, CITY/STATE/ I <br /> CONTRACTOR ADDRESS <br /> A/ 11--1 PHONE <br /> SUBCONTRACTOR/CONSULTANT o-� � <br /> ! <br /> SUBCONTRACTOR/CONSULTANT ADDRESS P CITY/STATE/ZIP � J <br /> �� IIL� EXPIRATION DATE J <br /> LICENSE _ C-57 a C-61 _ D-09 U Other2=0 <br /> ,i NUMBER <br /> BILLING PARTY: OWNER ri CONTRACTOR 7 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: D General MinerallColiform Bacteria(4391) = Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural _ Industrial _ Water Quality Monitoring _ Soil Sampling/Characterization <br /> Public Water System Contact Name or Phone Number <br /> If different from owner: Water System Name <br /> TYt5 RF WORK _ New Well U Replacement Well u Well Alteration/Modification J Other #of borings <br /> Monitoring Wells) #of wells U Soil Boring(S) <br /> #of borings - Geotechnlcal <br /> out-Of-Service Well u Out-Of-Service Well Renewal across-Connection Repair � <br /> -_ New Pump ❑ Pum Re lacem nt •]� Pum Re�a/ir C Raise Well Casing <br /> rEOINSTRUCTION U n ' Y r <br /> Method _ Mud Rotary L1 Air Rotary u Auger _ Cable Tool L_ Push Point Othed Well Depth ft Excavation in diameter u Open Bottom L_ Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> r) Steel a Plastic _ Stainless Steel a Other <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched <br /> ft � Neat Cement(941b bag/5-10 gal water) n Sand Cement sack mix/7 gal water <br /> Grout Seal Depth L <br /> Bentonite(20%solids) 11 Other U <br /> n Retardant/Accelerator(name) <br /> Grout Placement Method - Pumped ❑ Free Fall n Other <br /> PEDESTAL Installed By - Driller ❑ Pump Contractor C Other <br /> Cncrete Pedestal uDimensions:Width ft Length ft Thick in _ Christy Box U Stove Pipe <br /> PUMP ��Soubmersible- Turbine ❑ 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 CURRENT AND AC 'RDIWITH THE SCAL CALIFTATE ORNIA CONTRACTORS AND RULES NSTATE U LICENSE BOARD AND CERTIFYLATIONS. I ALSO HAT I AM NYCOMPLIANCE IW TH ALL <br /> WORKERS COMP S ON LAWS. <br /> MINIMU HOUR AQ�ANCE NOTICE REQUIRED FO INSPECT�S -y/P��LEASE CALL(209)�5��697 <br /> TITLE 0 Cp )C1 �7 J DATE 15 ILL) <br /> SIGNED <br /> I 7� <br /> i <br /> I <br /> r}'t <br /> S N O UPI O N <br /> H LT DE7A7T, ,ENT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By _�,��L Date /1 J o Area y _ Employee ID# ER <br /> Grout Inspection By nn Date ❑ SPECIAL Well Permit <br /> Pump Inspection By �nE.�� �. ° i�Ls� Date �� >Z`��1 ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ <br /> Codes Info B Cash Remitted Service Request# Invoice# Well ID# <br /> L438a oso 3�(6 #-7 I(7 2t) <br /> EHD 43-06 6/11/2019 <br /> WELL/PUMP PERMIT <br />