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r , <br /> 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.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> to <br /> JOB ADDRESS 11 -781 � ��l L l/ �� CITY/ZIP m <br /> T</— a <br /> CROSS STREET -,M V ///L/HP/N /(J/(] �Cx PARCEL SIZE LAND USE APPLICATION <br /> /# A <br /> -� �S�✓GLDN PHONE <br /> OWNER NAME �J /mac �/ <br /> OWNER ADDRESS CITY/STATE/ZIP �� Gly %�,/7 —Z77 el <br /> CONTRACTOR f /76 PHONE aW !�,Z '0` t/*-7 +� <br /> CONTRACTOR ADDRESS �LC'//Gf/bs�1� / CITYISTATE/ZIP �� O��Dl//JD q of Z�L <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATE/ZIP /� <br /> LICENSE X C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE_j9-31—1Z01ZQ <br /> BILLING PARTY: ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ?Oomestic/Private 0 Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well ❑ Replacement Well ❑ Well Alteration/Modification 0 Other <br /> ❑ Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> ❑ New Pum Pump Replacement 0 Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP gSubmersibleo Turbine ❑ Other HPPump Set 'ZZ 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 /> MINIMU 48 UR ADV C OTICE REQUIRED FO/Rl INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED <br /> SIGNED TITLE ` �SI�O/r�/jf��/ DATE 7/2 <br /> l <br /> ( <br /> Q \ <br /> l <br /> A <br /> HEATH DUART E14T <br /> FrARTMENT Up E O Y LY <br /> Application Accepted By _ Date 245 Area Employee ID# <br /> Grout Inspection By Date CI PECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info By Cash Remitted Date Service Re uest# Invoice# Well ID# <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />