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• WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1666 EAST HAZELTON AVENUE-STOCKTON CA 95206-6232(209)466-3420 <br /> NON-REFUNDABLE PERMIT Dw, WWw.S Ov.or /ehd EXPIRES I YEAR FROM DAT/E�ISSUED <br /> JOBADDRESS L WIV '/ CITY/Zip�1�01�, �JW <br /> CROSS STREET�� C APN ���,rA_'�� O 1 D PARCEL SIZJ 42- LAND USE APPLICATION#''')/( cy <br /> OWNER NAME 1/V fit- Mo1`�S Leri �,I PHONE qn3-3708 <br /> 08 <br /> OWNER ADDRESS V 0 X CITYISTATEIZIP R Y UN,C 1 ✓,3 v <br /> CONTRACTOR MG WONI T r_+5U* fq2'0 <br /> CONTRACTOR ADDRESS—LitraW FA. CITYISTATEIZIP MOdQ,Sfio P.) <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SU13CONTRACTORICONSULTANT ADDRESS CITYISTATEIZIP <br /> LICENSE )kC-57D C-61 0 D-09 0 Other NUMBER gV5022 �y���}EXPIRATION DATE " r,30•2�I <br /> BILLING PARTY: 0 OWNER 0 CONTRACTOR ❑ SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:D General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)D Arsenic(4393) <br /> INTENDED USE Domestfc/Prlvate 0 Irrigation/Agricultural D Industrial 0 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 ❑Replacement Well 0 Well Alteratlon/MDdlficatlon 0 Other <br /> ❑Monitoring Well(s) #of wells 0 Soil Boring(s) s orborings 0 Geotechnical N of borings <br /> D Out-Of-Servlce Well 0 Oat-Of-Service Well Renewal ❑Cross-Connectlon Repair <br /> 0 New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rota 0 Air Rotary ❑Auger ❑Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth 30 It Excavation 12.10 in diameter 0 Open Bottom Gravel Peck/Gravel Size4W In diameter <br /> 0 ConductorCasingIn diameter / Conductor Casing Depth ft <br /> Well Casing DiameterIn Thickness/Gauge/ASTM Schad H/0 ❑Steel Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth2X0 It D Neat Cement(94 lb bag/610 gal water] 0 Sand Cement sack m1x17 gal water <br /> Bentonite(20%solids) 0 Other <br /> Grout Placement Method XPumped ❑Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor D Other <br /> ❑Concrete Pedestal ODimenslons:Width It Length ft Thick In D Christy Box ❑Stove Plpe <br /> PUMP ❑Submersible0 Turbine 0 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 /> MINIMUM V �OTICE REQUIRED FOONS-PLEASE CALL(2091,9,53-7697 <br /> SIGNED TITLE DATE <br /> �l° 41 ' � 0� <br /> 121° 1 . <br /> H T D c �11 <br /> DEPARTMENT U E[ONLY <br /> w GG / <br /> Application Accepted By l� Dale `' Lot f Area "I Employee ID#PIT ri <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By <br /> Date [I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#I Amount Data Permit/ Invoice# WellID# <br /> Codes Info B Cash Remitted Service Re ues # <br /> o 4W <br /> 'I <br /> WELL/PUMP PERMIT <br /> EHD 43-06 8!112019 <br />