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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1066 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)460-3420 <br /> NON-REFUNDABLE PERMIT www.s L ov.org/elid EXPIRES 1 YEAR FROM DATE ISSUED <br /> S <br /> JOB ADDRESS S I JiC I-- IA�_ - CITY/ZIP,ata/oil , <br /> �` D <br /> CROSS STREET IZ� _APN fit, -t '2(o�PARCEL SIZE115.030LAND USE APPLICATION# o <br /> L L 1_ m <br /> OWNER NAME lAVTwaryu Ir AIIt4onV PHONE <br /> ))�3, 1 SS v? <br /> OWNER ADDRESS , N ISI `• CITYISTATE/ZIP��S.0 G(/v�, �- 9S32� <br /> CONTRACTOR gtllif 13011M t')_y�/ . PH�OON 5122;lg2a <br /> 1 � <br /> CONTRACTOR ADDRESS 101 h I bS1 CY1 CITY/$TATE/ZIP I rlr�A�4`e s%` C-t W5-7 <br /> SURCONTRACTORICONSULI ANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE ,i�C-57 0 C-61 Ll D-09 11 Other NUMBER."8bzz EXPIRATION DATE (4-30'7,A- <br /> BILLING <br /> -3b+7+1'BILLING PARTY: -i OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:!I General Mineral/Coliform Bacteria(4391)11 Dibromochloropropane(4392)I i Arsenic(4393) <br /> INTENDED USE DDnlestic/Private 0 Irrigation/Agrlcultural D Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> D Public Water System — <br /> If different from O—r: Water Sy,lem Name Conlect Name or Phone Number <br /> TYPE OF WORK D New Weil LAepiacement Well 0 Well Alteration/Modification 0 Other <br /> 0 Monitoring Wells) #of wells U Soil Boring(s) d or bodng, D Geolechnical— e or boring, <br /> D Out-Of-Service Well 0 Out-Of-Service Well Renewal D Cross-Connecllon Repair <br /> 0 New Pump 0 Pump Replacement 0 Pump Repair U Raise Well Casing <br /> WELL CONSTRUCTION"4 <br /> Drilling Method ud Rotary rJ Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br /> Proposed Well Depth 250 fl Excavation- in diameter f-1 Open Bottom Gravel Pack/Gravel Size in diameter <br /> U CondU%Casing In diameter / Conductor Casing Depth it <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad� rJ Steel Plasllc n Stainless Steel 0 Other <br /> Grout Seal Depth �6 U If n Neal Cement(94/b bag/5-10 gal water) D Sand Cement sack mix/7 gal water <br /> (bentonite(20%solids) D Other <br /> Grout Placement MethodKPumped D Free Fall 0 Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal❑Dimensions:Width it Length it Thick in 0 Christy Box 0 Stove Pipe <br /> f PUMP 0 SUbmersiblel_1 Turbine 0 Other HP Pump Sel ft Standing Water Level 11 <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 /> 46 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209))953-7697 <br /> SIGNED TITLE ad--j"'rr DATE <br /> i )t• <br /> _ FHT <br /> T NT <br /> D PART •i .,E ONLY M <br /> Application Accepted By ' Dale Area+IPEIAL <br /> Employee ID# K111 <br /> Grout Inspection By_ Date— 1 Well Permit <br /> Pump Inspection By Dale <br /> I WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth _ft <br /> COMMENTS <br /> PE SC Receivedhack# Amount Perm it/ <br /> Date Invoice# Well ID# <br /> Codes Info B Cas Remitted Service Ret crest# <br /> o :6 D Dy -- <br /> S .2G t`1 O �j L <br /> 317 <br /> 0 I`1 W CJ 0105 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />