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�e <br /> WELL/PUMP PERMIT <br /> SAN JOAQuw COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgoV.oralehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> (JOB ADDRESS /��q I H DOV g r'l, ''v r`� T p 1 CITY21PAW,� '153917 A <br /> CROSSSTREET (1VCt)rr p APN-90go14Oa3 ._PARCEL SIZ�� ND USE APPLICATION! <br /> I <br /> OWNER NAME �ll//�ereAU G(`CryA4T�JCC� I,1nP e4-0.j _ _ _ _- _< PHONE t� CIA <br /> 'p �.t G <br /> OWNER ADDRESS jGd� i�I AJQ-1� 1 Li 3 CITY/STATE/LP JQ 6 r-A n^C"'ITor `'A1 q-5&6 <br /> CONTRACTOR /K'elcla f7w+li1 5 <br /> (gao l/e >,',,j. PNoNlE RY-k;53-Soa5 b 53 <br /> �f 16 <br /> j <br /> CONTRACTOR ADDRESS r.5y Al.,F LiII 15�Prt'-� /^ CITYISTATE/ZIP lJC'Av�}e,,/CA 9t�aC867�' - <br /> SUBCONTRACTORICONSULTANT__ 1-/n�ersS one jL�L(1 A�1r-U4 CPHONE jog-,'q5-y6do <br /> SUBCONTRACTORICONSULTANT ADDRESS 05 0/Q��K7 (Ar` -"tje CITY/STATEIZIP lUn n X�a��j `+' <br /> LICENSE K C-57 C 51 D-09 Other NUMBER g� ExPmTiclN DATE <br /> BILLING PARTY: OWNER CONTRACTOR X SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:-General MineraMotiform Bacteria(4391)D Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED U$E I Domestic'Pnvate ;:Intgation/Agricultural " Industrial f Water Quality Monitoring /Soil Sampling/Characterization <br /> Public Water System <br /> M dtMerent born.Owner Water Sretem Nome Conlod Name or Chane Number <br /> TYPE OF VYORK C New Well - Replacement Well -Well AlterationlModification Other <br /> .-Monitoring Weis) N of wells Soil Boring(S) s of` " h Geotechnical '5 e o1 bef"q�/C lorj <br /> C Out-Of-Service Well L Out-OfServioe Well Renewal -Cross-Connection Repair <br /> .- New Pump J Pump Re Ip acement Pum Re air Rase We'I Casing <br /> I WE-�CONSTRUCTION <br /> (Drilling Method Mud Rotary J Air Rotary ..Auger Cable Tool /Push Point I Other <br /> (Proposed Well Depth 50- 100 ft Excavatior in diameter - Open Bottom Gravel PackJGravel Size in diameter <br /> Conducto,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(94 It,bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> I Bentonite(20%solids) Other <br /> Grout Placement Method ' Pumped Free Fall /Other Ir .NniP. C Retardant l Accelerator,name) <br /> (PEDESTAL Installed By _ Driller _ Pump Contractor - Other <br /> Concrete Pedestal_Dimensions Widlh ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersiolei. Turbine .Other HP Pump Set IT Standing Water Level — It <br /> I HEREBY CERTIFY THAT 1 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 CALIFOR IA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS C(MPENSATION LAWS. <br /> 11 R .EVAN NOTICE REQUIRED PORAAAE INSPECTIONS -PLEASE CALL (2091 95'.-7697 <br /> SIGNED TITLt�(I/t't-1�LIJ7/.�'f�^c/1j01"-'-j-40 DATE ! -�L�-7 Ll•� <br /> kill <br /> t� <br /> viN� 2020 <br /> c <br /> T <br /> —TEL <br /> jEtAillitTMENT SY <br /> Application Accepted 8y / Date �� Area 7/ S-� Employee IDf1S(sI4NJ <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date _. WAIVER Received <br /> Soil Boring Inspection By Zun:)'q' ln.t/ Date O v Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Checke/ Amount PennlV <br /> Codas Info Cash Remitted Diate Service Request 0 Invoice A WON IDi <br /> I <br /> EM04306 6!11/2019 -- - - -- WELL/PUMP PERMIT <br />