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c� e► <br /> 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.sigov.org/ehd EXPIRES'I YEAR FROM DATE ISSUED <br /> 1 N <br /> JOB ADDRESS JI I,• \53wan 9,0oA CITY/MP�`,' 9 is BCA <br /> \r hM FCKY__ (d _APN Z�S 3 2 SO—30 42 3-I v <br /> CROSS STREET �v F`C`L TJ_PARCEL SIZE LAND USE APPLICATION L'_ 0 <br /> OWNER NAME \-•1\O\[ni `YC,Y'1r11�-'1�� PHONE-- <br /> OWNER <br /> OWNER ADDRESS -' i75o J• �nY\a11 F -+ CITYISTATEIZIP_ �Y� 1 C i4 I �� ✓V� __ <br /> CONTRACTOR W \`LMs \hL• _ PHONE _ f <br /> CONTRACTOR ADDRESS ,Nlb ab ��ACY�\�r{c^S� �Y\VL. 1 CITY/STATE/ZIP �\� ICA- f 05(,p3 .Z <br /> ` , <br /> SUBCONTRACTOR/CONSULTANT \d Pc cAZIC. rrT \� xcey\Y�.01 \y\L• PHONE _ <br /> SUBCONTRACTO <br /> R/CONSULTANT ADDRESS VlO O/V\ VWWY0 bl"%A CITY/STATE/ZIP -( a'41 G RSI/ <br /> LICENSE X-57-57 0 C-61 C —12.0104 <br /> D-09 D Other NUMBER 1 ZO 10\�f EXPIRATION DATE 'A 160 I;toao <br /> BILLING PARTY: ❑OWNER 0 CONTRACTO�UBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:D General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)D Arsenic(4393) <br /> tNTPAV=.ICE ❑DomestiGPrivate C IrrigationlAgricultural D Industrial 0 Water Quality Monitoring petoil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK C New Well C Replacement Well 0 Well AlterallonlModificalion0 Other <br /> 0 Monitoring Well(s)_#of wells 0 Soil Boring(s) rt of borings Geotechnical #of borings <br /> D Out-Of-Servlce Well C Out-Of-Service Well Renewal D Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement 0 Pump Reoair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary Auger D Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth LIQ ft Excavation 15~ in diameter ❑Open Bottom 0 Gravel Pack/Gravel Size In diameter <br /> 0 Conductor Casing in diameter I Conductor Casing Depth it <br /> Well Casing Diameter_in Thickness//GGaugelASTM Sched 0 Steel ❑Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth 140Wp ft eat Cement(94 Ib bag/5-10 gal water) D Sand Cement sack mix/7 gal water <br /> D Bentonite(20%solids) 7 Other <br /> Grout Placement Method 0 Pumped 0 Free Fall 0 Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By C Driller ❑Pump Contractor 0 Other <br /> 0 Concrete Pedestal❑Dimensions:Width_It Length ft Thick in 0 Christy Box C Stove Pipe <br /> uMP 0 SubmersibleO Turbine C Other HP Pump Sel it Standing Water Level it I <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 CO P8 TION LAWS. <br /> M HOOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)913-7697 <br /> SIGNED UR DVA TITLE M: <br /> _ AFF G, DATE <br /> I � ( <br /> MENr <br /> EI VE® <br /> SAN <br /> ' 0 2020 <br /> E�rM�O��'�,W� SOU <br /> HEA, nto1�IME�TAL Tl' <br /> MENT <br /> E ARTMENT USEO LYq C <br /> Application Accepted By Date -3/10/Z0,36 <br /> Area `� Employee ID# /u <br /> GroutlnspectionB Date - SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soll Boring Inspection By Date_ � / Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Date Perrnit/ Invoice# Well ID# <br /> Codes Info B Cash Ram@ted S Ice R uest# <br /> EH0 43-06 16/11/2019 WELL(PUMP PERMIT <br />