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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)4683420 <br /> NON-REFUNDABLE PERMIT WWW.SjgOv.0r lehd EXPIRES 1 YEAR FROM RA ISSUED Ln <br /> JOB ADDRESS CINILIP I� <br /> � q� D <br /> CROSS STREET AP N ARCEL SIZE,� 14 <br /> _YNO USE APPLICATION# <br /> trft In <br /> OWNER NAME ,l J '%r PHONE 1Nn, <br /> OWNER ADDRESS W V �� a-1 L -7 n r. CITYISTATEIZIP �7 ^� <br /> CONTRACTOR Goo-EX SU SU[ -�-1(l�X� �Gy%�� �CA I� PHONE ?�l� -J z <br /> CONTRACTOR ADDRESS I�I 0 1`�ri�.d QlG IdJ(1/'0 CITY/STATE21P f)ami)C4 Iq5 b 26 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITYISTATEIZIP <br /> LICENSE Q1657 ❑C-61 ❑D-09 ❑Other NUMBERG'S42t071 EXPIRATION DATE <br /> BILLINGPARTY: ❑OWNER UeONTRACTOR ❑SUBCONTRACTORJCONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDEp USE ❑Damestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring NRor'oil Sampling/Characterization <br /> ❑Public Water System <br /> IfdhTerent from Ormer. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Afteration/Modification ❑Other <br /> ❑Monitoring Well(3) #OfWeII3 l oilBOring(s)_ ` Sof borings Veotechnical Fofhorings u <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair 7 <br /> ❑New Pump ❑Pump Replacement D Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ;IPush Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing In diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth g_ft QNeat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method umped ❑Free Fall ❑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 ❑Submersible❑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 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 /> MINIMI(IM3 R ADVAMCEtYIOILGE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED = m TITLE ae,,i DATE 2 <br /> F�MENT <br /> R 5 ?420 <br /> Nc <br /> EPg R T FNT y <br /> DEPARTMENT USE ONLY C <br /> Application Accepted By Date Area Employee ID# J <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring�Inspection By pr 1'k^9)[9�t. Date 1`t (�1..� Constructed Well Depth ft <br /> COMM ENTS.� ' `LA---rt-/(��' 9 —2'40 V--Izn 3 <br /> PE Sc Received Chec Amount Date Permit/ Invoice WeIIID#' <br /> Codes Info emitted Service Re uest# <br /> �i z �� , <br /> EHD 43-06 6/118019 WELL/PUMP PERMIT <br />