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WELL/PUMP PERMIT <br /> V SAN JOAQUIN COUNTY ENVIRONME L HEALTH DE AR NT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT Z www.sigov.org/ohd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP S&C \\'va A m <br /> CROSS STREET / APIN PARCEL SIX*aG.LAND USE APPLICATION# p <br /> 71pN�.•"w? m <br /> OWNER NAME puvA <br /> ,yyP,,HHONN..�E <br /> OWNER ADDRESS CITYISTATE/ZIP�� o�oI C ay q t P IDC <br /> CONTRACTOR ,% WADI, PHONE <br /> CONTRACTOR ADDRESS ^ �1_ r f p J J� CITY/STATE21 <br /> SUBCONTRACTOR/CONSULLT"AN_T, I`90AI 94- tj � _ _ PHONE <br /> SUBCONTRAC�TO�C: 71ii '/- <br /> RICONSULTANT ADDRESS fC'ITY/STATtEMPn�- <br /> LICENSE II -b7 C-61 D-09 ❑Other NUMBER 0 EXPIRATION DATE <br /> BILLING PARTY: '�OWNER U-CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT l <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE D Domestic/Private D IITigationlAgricultural ❑Industrial -Water Quality Monitoring oil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK -New Well D Replacement Well D Well Alteration/Modification ❑Other � � <br /> D Monitoring Well(s) #of wells [I Soil Boring(s) #of bodngs B'Geotechnical #or borings <br /> 0 Out-Of-Service Well D Out-Of-Service Well Renewal D Cross-Connection Repair <br /> D New Pump D Pump Replacement 7 Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary L Air Rotary 9Kuger ❑Cable Tool C Push Point - Other <br /> Proposed Well Depth 6 ft Excavation in diameter D Open Bottom ❑Gravel Pack/Gravel Size In diameter <br /> i i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad -3 Steel 7 Plastic D Stainless Steel -Other <br /> Grout Seal Depth ft *last Cement(94 Ib bag/5-10 gal water) -1 Sand Cement sack mixl7 gal water <br /> 0 Benton a�/(20%solids) C Other <br /> O� <br /> Grout Placement Method PUmped C Free Fall ❑Other C Retardant i Accelerator(name) <br /> PEDESTAL Installed By ❑Driller 0 Pump Contractor 7 Other <br /> LJ Concrete Pedestal LiDimensions:Width ft Length It Thick in L Christy Box L Stove Pipe <br /> PUMP I I Submersible i Turbine i Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 R ADVANCE NOTICE REQUIRED FOR INS CTIONS-PLEASE CALL(209)953-7697 <br /> 4,:t &%Ab-Q(SIGNED TITLEDATE <br /> VED <br /> 4 2019 <br /> Q /N CO <br /> � MEMTq�Ty <br /> PAIR TMEnl7 <br /> P` MENT U§tt O YLY AA <br /> Application Accepted By Date ( Area L j_ Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By 1 ei Date ❑ WAIVER Received <br /> Soil Boring Inspection By 71,,1 b A 7LL -jjAZ Date 2 Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info By Cash Ilemitted Date Service Reg uest# Invoice# Well ID# <br /> t� WP0040 1 Q0 <br /> S <br /> EHD43-06 6111/2019 WELL/PUMP PERMIT <br />