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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 1NWW.s ov.Or /ehd EXPIRES'I YEAR FROM DATE ISSUED <br /> Yh N <br /> JOB ADDRESS l5 ) crtAck �a fl�/�/��Zr�� CIT^YIZI/P' K1D0"_,mow Rl <br /> D <br /> CROSS STREET �I AP APN /nj—VQ� , PARCEL SI J•104. LAND USE APPLICATION# o <br /> OWNER NAME �'"c��r1`s LOU PHONE •"7 ��355 <br /> OWNER ADDRESS I ssw Q���1-1� �/�MnD � CIN/STATEIZIP QL�Voj!!t i7rot <br /> CONTRACTOR LLIiS r-1 V` I PHONE <br /> CONTRACTOR ADDRESS CITYISTATE/ZIP Med YS fo / <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE21P <br /> LICENSE XC-57 D C-61 0 D-09 0 Other NUMBER L�✓ " EXPIRATION DATE 44'-30 <br /> BILLING PARTY: D OWNER ❑CONTRACTOR ❑ SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)U Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE Domestic/Private D Irrigation/Agricultural ❑Industrial 0 Water Quality Monitoring D Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: Water System Neme Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well D Well Alteration/Modlficatlon 0 Other <br /> ❑Monitoring Wells) #of wells ❑Soil Boring(s) <br /> p of borings ❑Geotechnical #'of borings <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement 0 Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary 0 Air Rotary ❑Augerr ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth 77 Excavation l Z" In diameter ❑Open Bottom Gravel Pack/Gravel Si, In dlameter <br /> ❑Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter (m In Thickness/Gauge/ASTM Schad__2AY-'> 0 Steel WPIaStiC ❑Stainless Steel D Other <br /> Grout Seal Depth /CFO ft D Neat Cement(94/b bagl5-10 gal water) D Sand Cement sack mix/7 gal water <br /> 'yBentonile(20%solids) 0 Other <br /> Grout Placement Method)(Pumped ❑Free Fall 0 Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Inst 1 11Pump Contractor 0 Other <br /> 0 Concrete Pedestal DDlmenslons:Width ft Length ft Thick in D Christy Box 0 Stove Pipe <br /> PUMP 0 Submersible 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 /> MI`IIM�P 448 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9533-77697 <br /> SIGNED �L TITLE �Y�� DATE_ —LO—�"� <br /> r <br /> 9 <br /> t <br /> A <br /> A J A UI C U <br /> N IR N E T <br /> �Wc PARTMENT USE ONLYy <br /> Application Accepted By <br /> v Dale Z 6 17 I r Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By <br /> DateConstructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#! Amount Data Permit/ Invoice# Well ID# <br /> ServlceRe uest# <br /> Codes Info B Cash Remitted <br /> 7 �U y Z0 L 1l,,Z <br /> (N Z� <br /> WELL/PUMP PERMIT <br /> EHD43-06 6/11/2019 <br />