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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.S OV.or /ehd EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS mr-!k1 IC CITY/ZIP F"'X k &L" <br /> CROSS STREET Pt T•` APN I q3-ISI O' 3 3 PARCEL SIZE Z"LAND USE ArPPPPLICATIONa#�/� v <br /> OWNER NAME e d PdONE t 4t- S%6 <br /> OWNER ADDRESS 20001 1:- T-ICI � r�L(y�- CITY/STATE/ZIP 'de 11 („_q /SuL <br /> CONTRACTOR rAns IellisA IID-rAh ryt(.r —T.0 PHONE SZZ�Vt2g <br /> CONTRACTOR ADDRESS l q A IID�(S Rd, CITY/STATE/ZIP (S CA <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SU13CONTRACTORICONSULTANT ADDRESS CITY/STATE/ZIP ss <br /> LICENSE X C-57 0 C-61 0 D-09 0 Other NUMBER 2 EXPIRATION DATE f, •0 f <br /> BILLING PARTY: 0 OWNER ONTRACTOR 0 SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE D Domesti./Private Irrigation/Agricultural 0 Industrial D Water Quality Monitoring 0 Soli Sampling/Characterizallon <br /> D Public Water System <br /> If different from Owner: Water Syatam Nem. Confect Name or Phone Number <br /> TYPE OF WORK XNewWell 0 Replacement Well 0 Well Alteratlon/Modi9catlon 0 Other <br /> D Monitoring Well(s) #of wells O Soll Boring(s) #of bodnge 0 Geotechnical #of boring. <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement D Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method`(Mud Rotary 0 Air Rotary 0 Auger 0 C 7ble Tool 0 Push Point 0 Other <br /> Proposed Well Depth 350 ft Excavation��In diameter D Open Bottom )(Gravel Pack/Gravel Size_-ez_in diameter <br /> 0 Conductor Casing In diameter / Conductor Casing Depth ft <br /> Well Casing Dlameter12- In Thickness/Gauge/ASTM Sched DO 0 Steel )(Plastic 0 Stainless Steel D Other <br /> Grout Seal Depth—Sb it D Neal Cement(94 lb bagl5-10 gal water) 0 Sand Cement sack mixr7 gal water <br /> Bentonite(20%solids) 0 Other <br /> Grout Placement Method xPumped 0 Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal ODimensions:Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP D SubmerslbleO Turbine 0 Other HP Pump Set ft Standing Water Level fl <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 /> Ml j!G46 HOUR ADVANCE NOTICE REQUIRED FOR/INSPECTIONS-PLEASE CALL(209))9953-7697 Q <br /> SIGNED �r.►-� TITLE DATE <br /> O N <br /> IR N E <br /> 9N T <br /> H H <br /> PARTMENT USE ONLY <br /> Application Accepted By ^ Dale e� Area-,% Employee ID#��-� <br /> Grout Inspection By Date SPECIAL WeII Permit <br /> Pump Inspection By Date O WAIVER Received <br /> Soil Boring Inspection By / Date Constructed Well Depth ft <br /> COMMENTS (j n/S r ,� / a: /(R) <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info A B C sh Remitted Service Request# <br /> L3(2-q- JW V41759f I? <br /> EHD 43-08 6/11/2019 WELL'PUMP PERMIT <br />