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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 /> ��.,�/,,�/^/ f�-- - <br /> JOB ADDRESS CITY/ZIP =•f..., 115at-S_ <br /> rmn <br /> D <br /> CROSS STREET I ILA F-t7t _APNC� PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME V _ PHONE C;M_q3t��C m <br /> OWNERADDRIESS e CITY/STATE/ZIPkrM�.(-j4� �L (J <br /> CONTRACTOR Oowm_ PHONE !`L -5,M D <br /> CONTRACTOR ADDRESS O Wcao CITY/S'rATE/ZIP /� Y� <br /> SUBCONTRACTOR/CONSULTANT PHONE� _ <br /> SUBCONTRACTOR/CONSULTANT ADDRESS C TY/STATE/ZIP <br /> LICENSE �C-57 ❑ C-61 r] D-09 U Other NUMBER VJ EXPIRATION DATE �I- <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391), Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> U Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK r7 New Well ❑ Replacement Well ❑ Well Alteration/Modification r.] Other <br /> ❑ Monitoring Wells) #of wells n Soil Boring(s) #of borings n Geotechnical #of borings <br /> ❑ Out-Of-Service V <br /> Vell ❑ out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump A Pump Replacement ❑ PUrnp Repair Ci Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary n Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter U Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(941b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) 1-1 Other <br /> Grout Placement Method rl Pumped U Free Fall ❑ Other U Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal UDimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine ❑ Other HP Pump Set___Z 2V ft Standing Water Level <br /> C <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 /> MIN "0' �NCEE REQUIRED FOR�PECTIONS -PLEASE CALL(209)953-7 97 <br /> SIGNED TITLE t/,�//� ` DATE �f 4 <br /> �r <br /> - o <br /> c <br /> D N 1Y <br /> Lnj <br /> FT <br /> EPARTMENT US ONLY /jpdployee <br /> '/ <br /> Application Accepted By _ Date Area ID# _ c— <br /> Grout Inspection By Date op PECIAL Well Permit Inspection By� Date 11 1V I _ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth _ ft <br /> COMMENTS <br /> PE SC ReceivedChec Amount Permit/ <br /> Codes Irrfo B Cash Remitted Date Service Request# Invoice# Well ID# <br /> II 1�-r <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br /> IJ <br />