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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 /> 3/9 D ©rte /2� , �/ <br /> JOB ADDRESS CITY/ZIP m <br /> /ri // D <br /> CROSS STREET ^� _APN �O J���O—4M6 PARCEL SIZE�l—LAND USE APPLICATION# o <br /> J/�O� p y 0 <br /> OWNER NAME �/ v ' /_Y�^ `� PH�O/Nlr�[ y A� Gvj� <br /> OWNER ADDRESS �I /+/L / � CITY/STATE/ZIP <br /> CONTRACTOR _ --e PHONE'' <br /> CONTRACTOR ADDRESS_ CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT _ J� i�Z/C,.Lzj PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE ( 57 f 1 ❑ D-09 ❑ Other NUMBER_���L�0. EXPIRATION DATE <br /> BILLING PARTY: OWNER i)CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) I Dibromochloropropane(4392) Arsenic(4393) AYNj <br /> INTENDED USE 40 WDomestic/Private 0 Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characteri25MG61 <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number Ulu; 01 <br /> TYPE OF WORK New Well ❑ Replacement Well LI Well Alteration/Modification r_❑ Other $,qN <br /> 0 Monitoring Well(s) #of wells ❑ Soil Boring(s) #or borings ❑ Geotechnical_ H E J 40 <br /> WIN <br /> ❑ Out-Of-Service Well 11 Out-Of-Service Well Renewal CI Cross-Connection Repair STH p AITAL <br /> 11 New Pum ❑ Pum Replacement ❑ Pum Repair ❑ Raise Well CasingNewl <br /> WELL CONSTRUCTION <br /> Drilling Method <br /> ,)DMud Rotary ❑ Air Rotary CI Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth_3, 70 ft Excavation Z2- in diameter ❑ Open Bottom )YGravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_,61in Thickness/Gauge/ASTM Sched Ck 11Steel *Plastic ❑ Stainless Steel 0 Other <br /> Grout Seal Depth IDD ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> 1015tentonite(20%solids) ❑ Other _ <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in Ll Christy Box ❑ Stove Pipe <br /> [Pump )dSubmersible❑ Turbine ❑ Other HP_ 5 Pump Set ft Standing Water Level ZZB 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI R CE N��OTTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209)953-7 97 <br /> SIGNED /l���— _ TITLE_ '/j�l.�/L DATE <br /> e 17— <br /> ;ell T <br /> Nil <br /> Lo <br /> DE ARTMENT USE NLY <br /> Application Accepted By Date /U AreaEmployee ID#� � <br /> Grout Inspection By Date �CIALellPermit <br /> Pump Inspection By ry^E[ Seo [orrtica` *�n _ Date �I ht,\ t� _ WAIVER Received �� <br /> Soil Boring Insp etion By Date C nstructed Well Depth ft <br /> COMMENTS S <br /> 1. a InI <br /> PE SC Received Ch Amount Permit/ <br /> Codes Into B Cash Remitted Date Service Request# Invoice# -'Well ID# <br /> 4 I Co <br /> _ !o POO 4 O <br /> L_ S <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />