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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 LA <br /> JOB ADDRESS 1 CTo ry CITY/ZIP VQ�Q/'L , / y I J fll I___ _ m <br /> CROSS STREET _ _ 'SAP,.N�2r2p�-2(0 - b__PARCEL SIZE 16.3 LAND USE APPLICATION# r <br /> OWNER NAME 3eSuS S D*.awL �.J�+� ���Q ------ PHONE S5� (OS95-a-3- I L vii <br /> OWNER ADDRESS 1bS$1 .01 CA p!1It CITY/STATE/ZIP ktdal,G �/� <br /> it 461 <br /> CONTRACTOR 14\40 it r � _hC• __ __ PHONE $22.- I!q Mel <br /> ADDRESS i q A l bt r s CITY/STATE/ZIPOd s,0, 60k 1 6357 <br /> SUBCONTRACTOR/CONSULTANT __ PHONE_ <br /> SUBCONTRACTOR/CONSULTANT ADDRESS_ CITY/STATE/ZIP <br /> LICENSE )(C-57 F1 C-61 D D-09 Ll Other NUMBER 66Z4,2Z EXPIRATION DATE L1_ <br /> BILLING PARTY: [i OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE X Domestic/Private n Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well 0 Replacement Well ' ❑ Well Alteration/Modification 0 Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> I=1 Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> n New Pump ❑ Pump Replacement 0 Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)(Mud Rotary /n Air Rotary ❑ Auger 0Cable 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-L in Thickness/Gauge/ASTM Sched zoo ❑ Steel Xplastic ❑ Stainless Steel ❑ Other <br /> Grbut Seal Depth_J0O ft ❑ Neat Cement(94 Ib bag/540 gal water) ❑ Sand Cement sack/nix/7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method f] umped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 1XPump Contractor o Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length it Thick in ❑ Christy Box 0 Stove Pipe <br /> rPuMP ❑ 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209) 953-77697 <br /> SIGNED ' TITLE_ Uy" KI DATE <br /> Jy <br /> U <br /> 0 1 F <br /> D P A R T M E N T U S E N L Y <br /> Application Accepted By -- - Date Area Employee ID#� � <br /> Grout Inspection Byr Date PECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Construe d Well Depth ft <br /> COMMENTS 11—�,rjffr _dadj t_ ef.� _JAI _- PCjL4gj&(C&Zf <br /> PE Sc Receivedec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Re uest# <br /> dwa 130 OW-7 . Z4) to --WP 0 I <br /> � _10-01401WP ou o <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />