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WELL/PUMP PERMIT <br /> AN 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 /> JOB ADDRESS 7 J/� 7 S' V.1 /l(fW v` CITY/ZIP 55;-(fa law 32 U m <br /> D <br /> CROSS STREET tlQ7alle Y! //2-0 � <br /> APN c PARCEL SIZE A F3 LAND USE APPLICATION# <br /> OWNER NAME ['l o t>L°)`t Alu tl!! G S 4,r/�C 2) e �q `hl a s PHONE'20 9 3 � y <br /> n <br /> OWNER ADDRESS 17-32 7 S'VA 41 0 1 l e h RSI CITY/STATE/ZIP �S CQ l0';01 / Loci rr s 3 ZU <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE _ C-57 _ C-61 _ D-09 - Other NUMBER EXPIRATION DATE <br /> BILLING PARTY: _OWNER _CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USEtlic <br /> estic/Private Irrigation/Agricultural Industrial Water Quality Monitoring _ Soil Sampling/Characterization <br /> Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK _ New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTfON <br /> Drilling Method _ Mud Rotary Air Rotary Auger Cable 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 in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(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 _ Christy Box _ Stove Pipe <br /> PUMP _ 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209)/,953-7697 <br /> SIGNED (Y'/ tK ���` �� TITLE d'"�`L117�'L DATE `'f� /l <br /> Al- <br /> -9 <br /> C <br /> F <br /> EP RTMENT U,SE N L Y <br /> Application Accepted By Date ` J Area Employee ID# <br /> Grout Inspection By Date C APECIAL Well Permit <br /> Pump Inspection By Date I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS O(� <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash emitted Date Service Request#:dV 1—F5 Invoice# Well ID# <br /> 6 Z WPO04-0 110 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />