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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 M/VI/W.s Ov.01' /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1751 JOB ADDRESS pY/t-tOln ({D 0. CITV/ZIP r� <br /> / D <br /> CROSS STREET I+/��'1v l ) APNOSS 1301 6 PARCEL SIZEI&C�V'145 LAND USE APPLICATION# A <br /> OWNER NAME l-1 i(-7 l,�,O LO�7�! 1 PtHON oq C)C3-733 -('?-Ito C) in <br /> OWNER ADDRESS Z Z 1 W /Pt`A [' e_{_Pi 1 CITY/STATE/ZIP LOCI t C/CA- 1! ✓`qO <br /> CONTRACTOR .(�eoLO/t (.,O t�S U Tit Yl/V5! I YL G.,J�-.(,' PHONE(/ (`�/ S Z— oI I <br /> CONTRACTOR ADDRESS 3 I(J'0 �-,p�of 0,11 e7 Prr, YobyD CITY/STATE/ZIP o rdOVn � 1S:'w( <br /> SUBCONTRACTOR/CONSULTANT V JW Dr)IQI i'Aq/�J` 2101 <br /> 01-e <br /> � PHONE �r / <br /> SUBCONTRACTOR/CONSULTANT ADDRESS II33 UIG .UvS f 1✓r I V� CITYISTATEIZIP ,`� �b 2-- <br /> LICENSE jc�C-57 0 C-fit 0 D-09 IJ Other NUMBEJZL 70 q EXPIRATION DATE t O1 Zo <br /> BILLING PARTY: D OWNER /CONTRACTOR - SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:D General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)D Arsenic(4393) <br /> 0 Domestic/Private 0 Irrigation/Agricultural LiIndustrial 0 Water Quality Monitoring U Soil Sampling/Characterization <br /> D Public Water System <br /> riN� <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK D New Well ❑Replacement Well -1 Well Alteration/Modification 0 Other <br /> U Monitoring Well(s) #of Its /Soil Borings) #of borings i Geotechnical #of borings <br /> 0 Out-Of-Service Well C Out-Of-Service Well Renewal C Cross-Connection Repair <br /> D New Pump J Pump Replacement L Pump Repair a Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rot ry 0 Air Rotary /Auger ❑Cable Tool D Push Point C Other <br /> Proposed WeII Depth I� IS ft Excavation in diameter J Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> 7 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched J Steel 0 Plastic 0 Stainless Steel 1-i Other <br /> Grout Seal Depth 15 0 ft f<eat Cement(94/b bag/5-10 gat water) 0 Sand Cement sack mixl7 gal water <br /> u Bentonite(20%solids) 0 Other ���/ <br /> Grout Placement Method 7 Pumped 0 Free Fall Y Other i-1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By Cl Driller C Pump Contractor 0 Other <br /> 0 Concrete Pedestal[]Dimensions;Width ft Length ft Thick in 0 Christy Box C Stove Pipe <br /> PUMP :']Submersible-ITurbine 0 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERSPEON S. <br /> MIN U 8 HO ADVA CE O CE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE`J f• J 1�'Ci �?�npwl DATE <br /> 00, lf <br /> O rN Y <br /> A MENT U E O LY <br /> Application Accepted By ate Area EmployeeID# C�/JVI� <br /> Grout Inspection By Date t-I SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> ,may,`_ <br /> Soil Boring Inspection By "V/M�� Dale L Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash 'lted Serv'ce Re uest# <br /> D ' <br /> EMD<9-0S 6/1112019 �� (jam �D t �' I / /� wEll/PUMP PERMIT <br />