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WELL/PUMP PERMIT <br /> SAN JOAG CO TY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95206.-6232(209)460-3420 <br /> NON-REF ND LE PERMIT www.sigov.org/ehd ILXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADOREf <br /> !tr C Irv1Z P R,fly, q`J 386 m <br /> /� D <br /> CROSS STREET /1\I•C- APN 2y 7'ebe- J� _PARCEL SIZE Z•160LAND USE APPLICATION#?� p <br /> OWNER NAME T—r'CA �V 1 a%oy% PHgNE (0Ce <br /> S�ID 1ia+ 1if <br /> OWNER ADDRESS �1l0 W CITY/STATEIZIP R11p�„ Cc, S ry at <br /> r <br /> CONTRACTOR 14' IIsi 16Y`1111ii: Thi• PHONES 2,2- G/-1 l Z� <br /> CONTRACTORADDNEaa 1 1 Albert is CITY/STATEIZIP ( Im 7p S37 <br /> S7 <br /> SURCONTRACTOW/CONSULTANT PHONE <br /> SUBCONTRACTORM.ONSULTANT ADDRESS CITYISTATE/ZIP <br /> LICENSE R c-57 D C-61 U D-09 U Other NUMBER&pk&2Z EXPIRATION DATE (4'.?6'7—Z— <br /> BILLING PARTY: IOWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:I I General Mineral/Coliform Bacteria(4391)I I Dibromochloropropane(4392),!Arsenic(4393) <br /> INTENDED USE atic/Pdvale In Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring Ll Soil Sampling/Characterization <br /> 0 Public Water System <br /> M AeetuN Iran Owner Weler System Name Cmtecl Name or Phme Number <br /> TYPE OF WORK UN&w Wer 0 Replacement Well 0 Well AlteratlonlModlflcation 0 Other <br /> U Monitoring Well(s) #of wells U Soil Boring(s) If of borings D Geotechnlcal__#of borings <br /> n Out-((Service Well 0 Out-Of-Service Well Renewal U Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement 0 Pump Repair U Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method%dMud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br /> Proposed Well Depth 2160 ft Excavation 17.1 In dlameler D Open Bottom X Gravel Pack/Gravel Size in diameter <br /> D Conduct Caslrtg In dlameler I Conductor Casing Depth ft <br /> Well Casing Diameter In Thickness/Gauge/ASTM Schad 21MP— 0 Steel j(Plastic D Stainless Steel 0 Other <br /> Grout Bad Depth ZjCO R 0 Neel Cement(94 Ib beg/r 10 gal water) 0 Send Cement sack mW7 gal water <br /> XBsrNalile(20%solids) 0 Other <br /> Grout Placement Method Pumped 0 Free Fall 0 Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal ODlmenslons Wldlh it Length ft Thick in 0 Christy Box U Stove Pipe <br /> PUMP 0 SubmersibleU Turbine U Other HP Pump Sel it Standing Water Level fl <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)963-7.6�9s7 <br /> SIGNED��� TITLE q'(I+Y��� DATE <br /> I Low, <br /> l <br /> F71FI FT <br /> 3 <br /> DEPARTMENT USE ONLY TMNiy <br /> Application Accepted By Dale S? Area - .}.. <br /> Grout Inspection By <br /> Date ! SPEC AL Well Permit <br /> Pump Inspection By Date I WAIVER Received <br /> Soil Boring Inspection By _ Date Constructed Well Depth ft <br /> COMMENTS /4 tr r <br /> PE SC Received heck#/ Amount Dale Permit/ Invoice# Well ID# <br /> Codes Info By Remitted ServlceRe uest# <br /> WELL/PUMP PERMIT <br /> EHD 43-W 6/11/2019 <br />