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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-REFUN ABLE PERMIT www.sjgov.org/ohd EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1 N <br /> JOB ADD ESS . .�� /�Ra CITY/A-4--LAND <br /> Z1IP,*A/`� /yl 15 � <br /> CROSS STREET `� APN Ir-)o o ISA PARCEL SIZE A-4 LAND USE APPLICATION# <br /> C7I.A-5 4C 14/SX(M IY'-G> Y�-C 4 I Q-a_P�CTTT�PHONE t� <br /> OWNER NAME ,/I '�(_•. /- ,. _\ rl� /�- .,.1/,�n <br /> OWNERADDRESS1P'�7 n fJ� _�7LO-6 T CITY/STATE21P� ..P <br /> 'fit`—r7D a ,n <br /> CONTRACTOR 1 PHONE 0- 60 Q/1�yIT� <br /> CONTRACTOR ADDRESS t 0 CITY/STATE/ZIP CI-..nU{lrn IG'��L. <br /> SUBCONTRACTORICONSULTANT�Y�*T 98 �) OM's d PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS � 11W� �(� CRYISTATEMP A QIlrI n <br /> LICENSE WCC-57 D C-61 D D-09 D Other NUMBER EXPIRATION DATE — <br /> BILLING PARTY: D OWNER \CONTRACTOR D SUBCONTRACTOWCONSULTANT <br /> DOMESTIC WELL SAMPLING:D General Mineral/Coliform Bacteria(4391)17 Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private D Inigation/Agricultural D Industrial ❑Water Quality Monitoring latoil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well D Replacement Well D Well Alteration/Modification ❑Other <br /> D Monitoring Well(s) #of wells D Soil Boring(s) #of borings } otechnicel *of borings <br /> D Out-Of-Service Well D Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> D New Pump D Pump Replacement 7 Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION � <br /> Drilling Method D Mud Rotary C Air Rotary :)Auger D Cable Tool re ush Point C Other <br /> Proposed Well Depth it Excavation in diameter 7 Open Bottom D Gravel Pack/Gravel Size in diameter <br /> I I Co idu or Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 3 Steel 7 Plastic D Stainless Steel D Other PqY <br /> Grout Seal Depth It 14i�ea <br /> � t Cement(94/b bag/5-10 gal water) Sand Cement sack mix17 gal water MEQ <br /> ❑Bentonite(20%solids) C Other �►^� <br /> Grout Placement Methodh�umped C Free Fall Other C Retardant/Accelerator(name) v ® �® <br /> PEDESTAL Installed By D Driller D Pump Contractor 7 Other I [� <br /> U Concrete Pedestal UDimensions:Width it Length It Thick in L Christy Box L Stove Pie ' �o®IQ <br /> PUMP I I Submersible I Turbine I Other HP Pump Set It Standing Water Level ''``,,,�-- °`�' <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE W ��/At � <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENS �p F q <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL �r <br /> WORKERS COMPENSATION LAWS. ARTMFl4j <br /> MINI M�ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED_ low TITLE � is 6InAtTO_t DATE <br /> A, TMENT US NLY <br /> Application Accepted By Area Employee ID#j1 rob <br /> Grout Inspection By Date ❑ PECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection B 9 n^ Date I1 21 i �I Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date PermiU Invoice# WeI11D# <br /> de Info Ca Remitted S ice Request# <br /> EHD 43-O6 8/1112019 JY J�/� �,I WELL/PUMP PERMIT <br />