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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.Sjggv.org/ehd � EXPIRES 1 YEAR FROM DATE ISSUED <br /> Z <br /> JOB ADDRESS G I CIT /ZIP l � )� m <br /> D <br /> CROSS STREET v 1,t J Ii APN d aCIa 7 003 PARCEL SIZE 47? LAND USE��APPLICATION# A <br /> OC 3 m <br /> vo 1� PHONE <br /> OWNER NAME �mj �a!` � <br /> OWNER ADDRESS ✓ 3 b v /`�`� CITY/STATE/zl <br /> CONTRACTOR I [, I PHO/NE' <br /> CONTRACTOR ADDRESS 'I CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT lY [ /'tl PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP ry e <br /> y�( B ���v�0 ID D -Z <br /> LICENSE _ C-57 -1`C-61 _ D 09 Other NUMBER EXPIRATION DAT <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: G General Mineral/Coliform Bacteria (4391) _ Dibromochloropropane (4392)�- Arsenic(4393) <br /> INTENDED USE _ omestic/Private _ Irrigation/Agricultural _ Industrial _ 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 _i Replacement Well j Well Alteration/Modification _ Other <br /> of borings <br /> # <br /> Monitoring Well �s) #of wells Soil Boring #of borings s) - Geotechnical <br /> rZ <br /> Out-Of-Servic W I Out-Of-Service Well Renewal Cross-Connection Repair <br /> = New P Pump Replacement Pump Repair Raise Well Casing <br /> _ <br /> WELL CONSTRUCTION �{ <br /> Drilling Method _ Mud Rotary L' Air Rotary _ Auger _ Cable Tool Push Point _ Other J <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 Schad Steel L Plastic _ Stainless Steel u Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) 7 Sand Cement sack mix17 gal water <br /> - Bentonite(20%solids) :� Other <br /> Grout Placement Method - Pumped n Free Fall F Other Retardant/Accelerator(name) <br /> PEDE� STAL Installed By = Driller 71 Pump Contractor = Other <br /> _ Concrete Pedestal LiDimensions:Width ft Len th ft Thick in _ Christy BOX L Stove Pipe <br /> PUMP Submersible- Turbine n Other HP= Pump Set I ft Standing Water Level ft S <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 /> MINI , 48 HOU PV NOTICE REQUIRED FOFONSPECTIONS -(�PLEASE CALL (209) 76 <br /> SIGNED TLE J"' t� `'Ce-W W! 1 DATE 210 <br /> I � i <br /> I I _ <br /> I <br /> I <br /> o Ulco 2 <br /> A N U <br /> pAR <br /> DEPARTMENT USE ONLY <br /> Application Accepted By L_j"— i Date 9 as ao?o Area J� y Employee ID# r Q <br /> Grout Inspection By Date C SPECIAL Well Permit <br /> Pump Inspection By .Ctnnt;'5 A-2 Date jj\ 1-I WAIVER Received <br /> Soil Boring Ins action By Date Constructed Well Depth ft <br /> COMMENTS W �/F? S _op _P_ e <br /> t eck AmountPermit/Remitted Date Invoice# Well ID# <br /> Service Request#$7 2Z <br /> EHD 43-06 6/11/2019 <br />