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U U "! V��" LEVU <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.S ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CA CITY/ZIP� ridP <br /> CROSS STREET APN6) %� V v PARCEL SIZE AND USE APPLICATION <br /> 6 m <br /> n m <br /> OWNER NAME PHONE <br /> OWNER ADDRESS h-C�A CITY/STATE/ZIP , ndtn/ <br /> CONTRACTOR Q WZAY Sma`Y� --i a( PHONE <br /> CONTRACTOR ADDRESS O Vv� (�X �""' CITY/STATE/ZIP 5__1 <br /> SUBCONTRACTOR/CONSULTANT 1 A PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE XC-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br /> BILLING PARTY: ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private 0 Irrigation/Agricultural ❑ 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 0 New Well ❑ Replacement Well 0 Well Alteration/Modification 0 Other <br /> ❑ Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> 0 Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump X Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger 0 Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ 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 mix/7 gal water <br /> 0 Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall 0 Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine ❑ 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 /> M N MU 48 HOUR ADVANCE NOTICE REQUIRED F INSPECTIONS-PLEASE CALL(209) 953-7697 Qf <br /> SIGNED TITLE DATE I <br /> Will <br /> T <br /> D <br /> 99 <br /> NTY <br /> E IO4M L <br /> H H D PA ITFAENT <br /> EP RTMENT E NLY <br /> i r <br /> Application Accepted By Date ?� _ Area Employee ID# <br /> Grout Inspection By Date fl PECIAL Well Permit <br /> Pump Inspection By hrQ&IhGt 6X-VernDate F'1,191.6 1)�q U WAIVER Received <br /> v <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> o sInfo B Cash mitted Date Service Re quest# Invoice# Well ID# <br /> "X__ <br /> EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />