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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FR MDATE ISSUED <br /> JOBADDRESS - qj51 97• 1 Drj W"-r crryop STa r K Ni/ /c <br /> is <br /> 10, <br /> S w A7 Q Z y D <br /> CROSS STREET RE <br /> Jt! APN I�fl I p aZ PARCEL SIZE � LAND USE APPLICATION �^ A <br /> OWNER NAME "`A' IC.,T, LLlz,�y y PHONE ✓�Q 7�Z- ���y w <br /> OWNER ADDRESS A 1-71,Q cSA SAC S CE t ` CITY/STATE/ZIP QUI w4�A•P- CA °1y5N`s- <br /> CONTRACTOR A�AvAA I}ccp {Gt o �I��101'7 N��I��'A J _�• ,__ PHONE Z44 :44%')- 11QQ Vy <br /> CONTRACTOR ADDRESS 19`-3.� /S� W Ab✓ f�f�A'[� y. CITY/STATE/ZIP e5C C1'K'M AI �99511 <br /> SUBCONTRACTOR A1% W C,, Ab AN p0lWAr,.on` DD..PHO-NlE_�11% /�.`56 S—�p355 <br /> SUBCONTRACTOR ADDRESS�6 y Fi k z.�c,£rA1cD Q�- CITYISTATE21P)PAM40 �1 Q p.YA. c-Ay yv <br /> LICENSE C-57 D C-61 C D-09 D Other NUMBER (Pb V I Z I EXPIRATION DATE /j 3A <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)E Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE D Domestic/Private D Irrigation/Agricultural D Industrial D Water Quality Monitoring D Soil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well 7 Replacement Well D Well Alteration/Modification L Other <br /> D Monitoring Wallis) #of wells 0 Soil Boring(s) #of borings Geotechnical #of borings <br /> D Out-Of-Service Well D Out-Of-Service Well Renewal L Cross-Connection Repair <br /> D New Pump D Pump Replacement 7 Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rotary■'C Air Rotary Auger D Cable Tool C Push Point C Other <br /> Proposed Well Depth �70 it Excavation 37 in diameter 7 Open Bottom D Gravel Pack/Gravel Size-4A in diameter <br /> D Conductor Casing N A in diameter / Conductor Casing Depth_ j JA ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad J Steel J Plastic D Stainless Steel D Other <br /> Grout Seal Depth !1040 ft - Neat Cement(94 Ib bag/5-10 gal water) 7 Sand Cement sack mW7 gal water <br /> i i Bentonite(20%solids) ther <br /> Grout Placement Method Apumped ree Fall D Other E Retardant/Accelerator(name) <br /> PEDESTAL,,Jt)A Installed By L Driller D Pump Contractor 7 Other <br /> •' 1 Concrete Pedestal FiDimenslons:Width ft Length_ ft Thick in Christy Box F Stove Pipe <br /> PUMP NIA ❑Submersible:]Turbine 7 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 /> MI IMUM 48 O_UeRLA.DVAANCE NOTICE REQUIRED F R INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED ��' �MW� TITLE MC,�� il "A 11`4 AGre DATE Z-4\0 _ 1� <br /> Cr <br /> RE 7' <br /> CE jVF p <br /> FEB 212019 <br /> 80 DEPMENrAL N <br /> -RTI yFNT <br /> n DE ARTMENT USE N L Y <br /> Application Accepted By.`�'6W Date Area Employee ID#g f`_'r/��/� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date I� WAIVER Received <br /> Soil Boring Inspection By^gjNggffi 'Ga� la" Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted ice Re test# <br /> EHD43-06 revised 4/14/18 WELL/PUMP PERMIT <br />