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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 /> p ��e� iac���ecT <br /> JOB ADDRESS Q � w (aC.7iL7 Ue CITY/ZIP (��,� s m <br /> CROSS STREETtP�C NX�MZ-' 2� ���J� APN �pi "�"�) � PARCEL SIZE 121,0\ LAND USE APPLICATION# <br /> OWNER NAME 1 `LL�� �l ` A ►PHONE / f1� C+ <br /> OWNER ADDRESS C' , p`�(,"ke O d•' CITY/STATE/ZIP MuYJ-YL <br /> e1() <br /> CONTRACTOR }th�\(, P� 1Z1�� 1y Lkw_ eL ,+ PHONE���p�4, ,��/ _\ <br /> CONTRACTOR ADDRESS '/� ('J 1.{�-r11�(�t FI,��1 CITY/STATE/ZIP WrL{� <br /> U�=���e VLti1 � y ( <br /> SUBCONTRACTOR/CONSULTANT � U°Glc,1\e-`�J' ` , ^�P,.HyONE /' C���/� <br /> SUBCONTRACTOR/CONSULTANT ADDRESS iJ�/SO ��j AL1\ �V� CITY/$TATE/ZIPWCSI �LA( 1 Q1� SCA 156R)i <br /> LICENSE C-57 Ll C-61 11D-09 11 Other NUMBER —1 EXPIRATIONDATE <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial !i Water Quality Monitoring '� Soil Sampling/Characterization <br /> ❑ Public 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 /> F1 Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> L New Pum ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary �-Auger ❑ Cable Tool 11 Push Point ❑ Other <br /> Proposed Well Depth\_ft Excavation 6 in diameter Li 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 0 Other <br /> Grout Seal Depth \5 ft )k 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 F1 Pumped Free Fall )c Othe�lPYyl Wu _l Reiar ant Acce erator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal Ll Dimensions:Width ft Length ft Thick in l� Christy Box C Stove Pipe <br /> PUMP ❑ Submersible El Turbine I I 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 /> ` <br /> SIGNED ALA TITLE VJA 0,! ,-Aew f DATE ?121H Lp Z0 <br /> 'q (N <br /> T F <br /> FTT <br /> T <br /> D j PARTMENT S �,1ONLY �/J <br /> Application Accepted By Date v y� Area Employee ID#W4SW11 <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date �- z Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received (_Check#V Amount Date Permit/ Invoice# Well ID# <br /> odes 1912- By --Cls-h Remitted Service Re uest# <br /> 2 21 •ZD r, <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />