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WELL/PUMP PERMIT <br /> SAI`,JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd E�X,PPI'R�E,S^1 YEAR FROM <br /> FRO�MM DATE ISSUED <br /> JOB ADDRESS o� 1 C � �1 Uv 1 CITY/ZIP Flc--Q �' ► \-T1yJ1�� m <br /> 1��� till <br /> CROSS STREET APN PARCEL SIZE S LAND USE APPLICATION# o <br /> QHS G., q J m <br /> OWNER NAME �� P PHONE ld'�J —O� ` I u�i <br /> OWNER ADDRESS 2 CITY/STATE/ZIP <br /> CONTRACTOR r 1 Y_' PHONE (�[�n� <br /> CONTRACTOR ADDRESS R t. CITY/STATE/ZIP �G^ ,� ` l <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 USE _ omestic/Private _ Irrigation/Agricultural Industrial _ Water Quality Monitoring _ Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Num <br /> TYPE OF WORK New Well - Replacement Well _ Well Alteratio n/Modifl cation _ Other 0 If Ivit:P47.tt <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical RIC rveD <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair I��99 1 IV py <br /> ew Pump Pump Replacement Pump Repair Raise Well Casi / 2020 <br /> n <br /> WELL CONSTRU TION SAN JpAQUIN CO <br /> Drilling Method . Mud Rotary _ Air Rotary _ Auger Cable Tool _ Push Point Other ENV—w UN7Y <br /> Proposed Well Depth ft Excavation in diameter Open Bottom _ Gravel Pack/Gravel Size DEtj pARTM"meter <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 mix17 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 _i Dimensions:Width ft Length ft Thick in Christy Box _ Stove Pipe <br /> PUMP ubmersible_ Turbine - Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERT! 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 /> MK41MUM 48 HOUR.AaYANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697) J <br /> SIGNED ` L TITLE C)`'" VCJ DATE <br /> J <br /> EP RTMENT S ONLY <br /> Application Accepted By Date Area Employee ID <br /> Grout Inspection By Date C SPECIAL Well Permit <br /> Pump Inspection By, i Date I U i WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received aAmount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted �l Service Request# <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />