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oWELLlPUMP PERMIT �:tV <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1066 EAST HA2:ECTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.SjgOy.org/ehd EXPIRES-11 YEAR FROM DATE ISSUED fl/. <br /> Jon ADDRESS 1./ CITY/zIP <br /> m <br /> CROSS STREET I /U!/�(�/�////� APN A���--O�l�y�(7 PARCEL$2E g?7 LAND USSEEAPPLICATION Jt / O <br /> OWNER NAME % /// j/Ey'(�!�(/� PHONCi—�� <br /> r� )� <br /> OWNER ADDRESS CITYISTATEOP f'Y/F/p9 � <br /> CONTRACTOR �pJ�j/ j , � /��//1 p� _ PHONE <br /> CONTRACTOR ADDRESS �r/L� (/T/IGL�/C� CITYJSTATEtZIP /� <br /> SUBCONTRACTORICONSULTANT /// �GJ!a_ 7Z /s PHONE <br /> SUDCONTRACTORICONSULTANT ADDRESS CITYISTATEI7jP <br /> LICENSE l"`-57 1%,a1 f I 0-09 O Other NUMBER_4�6-T La EXPIRAnON DATE <br /> BILLING PARTY: :'OWNER :I CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:I i General Mineral/Coliform Bacteria(4391)11 Dibromochloropropane(4392)I.Arsenic(4393) AYM� <br /> INTENDED USE omestic/Privale O IrrigalionlAgricullural n Industrial D Water Quality Monitoring D Soil! E�V <br /> rJ Public Water System <br /> Ir lllrrerenl 4wm or— Willer System Name Conlacl Name or Phone Numher <br /> TYPE Or WORT( }VNew Well O Replacement Well 1)Well Alleration/Modificalion U Other SA, r 7��� <br /> - a or borings YI1� /11 <br /> I7 Monilodng Well(S) it of wells U Soil Borings) U Geolechnical ON Cp N <br /> O Out-Of-Service Well 11 Oul-Of-Service Well Renewal LI Cross-Connection Repair �ALT}f pEp✓;NTq� <br /> D New Pum 0 Pum replacement O Pum Repair D Raise Well Casi ART-, <br /> WELL CONSTRUCTION <br /> Drilling Melhod,^ud Rotary D Air Rotary CI Auger O Cable Tool U Push Point D Other <br /> Proposed Well Depth 20 if Excavation /Z in diameter D Open Bottom )IoGravel Pack/Gravel Size _in diameter <br /> U Condluao/r Casing in diameter I Colxiuctor Casing Depth ft <br /> Well Casing Diameter 1!L in Thickness/Gauge/ASTM Sched CL U Steel /Plastic O Stainless Steel O Other <br /> Grout Seal Depth /N f) fl U Neat Cement(94 Ib Dag/5-10 gat water) 0 Sand Cement sack mixl7 gat water <br /> ' terflomle(20%solids) D Other <br /> Grout Placement Method n Pumped U Free Fall U Other 11 Retardant I Accelerator(name) <br /> PEDESTAL Installed By O Driller n Pump Contractor Il Other <br /> D Concrete Pedestal UDlmensfons:Width ft Length fl Thick in U Christy Box 0 Stove Pipe <br /> PUMP YSubmersible❑Turbine U Other HP -5 Pump Sol--,4F_fl Standing Wale,Level 62 fl <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 /> MINI R CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7 97 <br /> SIGNED ''` ;��' TITLE <br /> DERARTMENT USE O N L Y <br /> Application Accepted By �'-'- Dole U Arca Employee IDH ' <br /> Grout Inspection By_ Dale $P CIAL Well Perinif <br /> Pump Inspection By Date _ I WAIVER,Received <br /> Soil Boring Insp Ction ay Dale C nstructed Well Depth ft <br /> COMMENTS "r. al�'6 ,�(� ,' � - 0 e c tsd1w <br /> PE Sc Received Che Amount Date Permit/ Invoice H .Well IDH <br /> Codes Info B Cash Remitted Service Request H <br /> � � 08' 00 401 Co <br /> ___ARND A__O I= <br /> EHD 4345 W I V2019 WELL/PUMP PERMIT <br /> __ X21• q���� �' �J <br /> t)i�.UV• �"r <br />