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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 /> JOB ADDRESS CITY/ZIP <br /> 1Q!2llN -I <br /> CROSS STREET R L SIZE LAND USE APPLICATION#�^i �7 <br /> OWNER NAME /Ol� �J /�/ID/SOL/`/yl�,�y 4C� PHO <br /> NEr/! 5L <br /> OWNER ADDRESS Z� ` /L�l ��� CIN/STATE/AP <br /> CONTRACTOR ` PHONE <br /> �f.� /�1 6 l.J <br /> CONTRACTOR ADDRESS gyp& ITYISTATE/ZIP c=T7/�/V ; <br /> SUBCONTRACTOR/CONSULTANTaT t-�f.e 'K L /"'a PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/LP <br /> LICENSE *C-57 /IA-61 D-09 Other NUMBER EXPIRATION DATE <br /> BILLING PARTY: OWNER CONTRACTOR G SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:11 General Mineral/Coliform Bacteria(4391) _Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE omestic/Private n Irrigation/Agricultural 0 Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> 5 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well -1 Replacement Well -1 Well Alteration/Modification ❑Other <br /> u Monitoring Well(s) #of wells L Soil Bodng(s) #of borings a Geotechnical #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> IVNew Pump D Pump Replacement D Pump Repair a Raise Well Casing <br /> WELL CONSTR TION <br /> Drilling MethodMud Rotary D Air Rotary 0 Auger a Cable Tool 0 Push Point a Other <br /> Proposed Well/Depth_2ft Excavation I'L in diameter 0 Open Bottom Pbravel Pack/Gravel Size in diameter <br /> 1-1 Conductor asing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched a Steel Plastic ❑Stainless Steel Other <br /> Grout Seal Depth �X ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mixl7 gal water <br /> kAentonite(20%solids) Other <br /> Grout Placement Method umped Free Fall D Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ump Contractor D Other <br /> E Concrete Pedestal LDi ensions:Width ft Length ft Thick in D Christy Box Stove Pipe <br /> PUMP ubmersible❑Turbine D Other HP Pump Set ft Standing Water Level <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 LAM IN COMPLIANCE WITH ALL <br /> WORKERS C N TION WS. <br /> Ni <br /> NOTICE REQUIRED FO NSPECTIONS- L A CALL(209)953-7697 <br /> SIGNED TITLE /� DATE <br /> OV 1 <br /> P,q)ek <br /> cF/V <br /> C <br /> -- 2019 <br /> QV/N C <br /> -67�7 <br /> TMENT U O L /%�Fpg'A/;, <br /> M � <br /> Application Accepted By Date Q Area Employee ID# J(A — <br /> Grout Inspection B. _ — Date 2 ❑ PECIAL Well Permit <br /> Pump Inspection ByC Date 9 ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#I Amount Permit/ <br /> Cade. 1040 B C sh Remitted Date Service Re uest# Invoice# WeIIID# <br /> �9 7V <br /> (� (V� <br /> -OB 1120 9 WELL/PUMP PERMIT <br /> rsv <br />