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ri <br /> 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 /> Ln <br /> JOB ADDRESS 3'566 GW—R.A&T&Y- CITY/ZIP <`�TbG.(GG%oma' ��+ _ m <br /> 1 D <br /> CROSS STREET—±>12.o ta,d C�+N�/ APN / / '� O PARCEL SIZE�q!LAND USE APPLICATION# i�v a <br /> OWNER NAME ►�J(0.L�I�/U/� 51-1 � ]411diI1k1' A PHONE �y/�/ � <br /> OWNER ADDRESS 9Z0 ,kel,4 AlI CITY/STATE/ZIP � .1� L�`LI�C�2� A / 7S 7 <br /> CONTRACTOR "b6 ho <br /> ILC f / �PIHONEaW AM 77Z-2757 <br /> CONTRACTOR ADDRESS <Y7�/�// `��iQ7�7 /�!/ CITY/STATE/ZIP /�jy� /�I�L7J� �� ��✓ �J <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/ST-AATE-/ZIPP Q 7 �J <br /> LICENSE 1%C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER ��//e/7/J EXPIRATION DATE �J ' ��— 20�[J <br /> BILLING PARTY: ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE i Domestic/Privat I r' ' n/A ' ItU ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> 0 Public Water Syst m �� <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 14 New Well 0 Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method )0 Mud Rotary ❑ Air Rotary 0 Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ?lob ft Excavation /y/�1 in diameter ❑ Open Bottom VGravel Pack/Gravel Size Y–/,(. in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter e2— in Thickness/Gauge/ASTM Sched:::�DQ Z 7 ❑ Steel IKPlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth //�/ ft ❑ Neat Cement(94 lb bag/5-10 gal water) Sand Cement /d•.Y sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped ❑ Free Fall 0 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 LrSubmersibleo Turbine ❑ Other HP `r Pump Set ft Standing Water Level ;Z7/A 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 IOUR AD NC NOTICE REQUIRED FOR <br /> INSPECTIONS -PLEASE CALL(209) 9/53-7697 L� <br /> SIGNED 7 ^q�'` TITLE ( ��G jC'll�/�� / DATE <br /> 1 <br /> E I <br /> THN <br /> ;4�MEAT <br /> pEP RT EN USE ONLY <br /> Application Accepted By Date « Area Employee ID# A <br /> Grout Inspection B Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date l ❑ WAIVER Received <br /> Soil Boring I pection By at Constructed Well Depth 0 ft <br /> COMMENTS <br /> PE SC Received Ch ck Am unt Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> G �-t IAlIn9 <br /> 2 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />