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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 /> JJ rn <br /> JOB ADDRESS -�Z.u C oo,V CITY/ZIP m <br /> D <br /> CROSS STREET S. (�aS�: jj��� �� ` A}PN PARCEL SIZE 0 LAND USE APPLICATION# A <br /> OWNER NAME Pw Qj lOJ �/�r_Y I' E ` /'1��kc n PHONE y <br /> OWNER ADDRESS CITY/STATE/ZIP LC c,�. /; Cf S 2 L10 <br /> CONTRACTOR (N2< < n, AA1c.JSe n T-4i f -co-o PHONE_2e4� 36-1-;J-701 <br /> 701 <br /> CONTRACTOR ADDRESS 9O'� Tn�.JS�✓�c1 Win CITY/STATE/ZIP LO-�i �� `lS2((3 <br /> SUBCONTRACTOR/CONSULTANT So.r� C" CnV-Xd PHONE Ck L..�10 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS S C�vac, c-`wuie- CITY/STATE/ZIP Sc,+� ctibc <br /> LICENSE YC-57 E C-61 E D-09 ❑ Other NUMBER 6(,,'1O ``I EXPIRATION DATE Z,I 20 t <br /> BILLING PARTY: -'OWNER E�CCONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: -,General Mineral/Coliform Bacteria(4391)1 ' Dibromochloropropane(439 ) Arsenic(4393) <br /> INTENDED USE _ Domestic/Private L Irrigation/Agricultural Industrial C 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 New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> Monitoring Well(s) #of wells a Soil Boring(s) #of borings Geotechnical 2 #of borings <br /> Out-Of-Service Well E Out-Of-Service Well Renewal i Cross-Connection Repair <br /> New Pump E Pump Replacement Pump Repair j Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary ❑ Air Rotary 's Auger _ Cable Tool -i Push Point E Other <br /> Proposed Well Depth ISI ft Excavation &" in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> q Conductor Casing in diameter ! Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched LlSteel -L] Plastic `- Stainless Steel Other <br /> Grout Seal Depth ft `Neat Cement(94 lb bag/5-10 gal water) a Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) LI Other <br /> Grout Placement Method - Pumped ree Fall ❑ Other E Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor I- Other <br /> Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in E Christy Box E Stove Pipe <br /> PUMP - Submersible a 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 COMPENSATION LAWS. <br /> MINIMUM 48 HCUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED �� TITLE ("-cr4 ys� DATE 16' 2S ZyIC( <br /> A I <br /> _Nle I <br /> H <br /> c ARTMENT USE ONLY <br /> Application Accepted By Date o Area c/Employee ID# S V__ <br /> Grout Inspection By Date C iPECIAL Well Permit <br /> Pump Inspection By q Date 1 WAIVER Received <br /> Soil Boring Inspection By t Date Constructed Well Depth ft <br /> COMMENTS cJ- <br /> PE SC Received heck# Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted S rvice Request# <br /> 437� oZPY 460SIOle- 1 Ll� <br /> EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />