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t � <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.sjgov.org/ehd RXPIRES 1 YEAR FROM DATE ISSUED <br /> - to <br /> JOB ADDRESS MOt>r CITY/ZIP IL10O IA <br /> /� D <br /> CROSS STREET loL �k�s /'1N'C. APN 2yS'bbb• 3°l _PARCEL SIZE 2-* OLANDUSEAPPLICATION#_ A <br /> OWNER NAME - ��►a (�SUII�_ _ PHONE (065- 10 130 N <br /> — c - -- — <br /> OWNER ADDRESS 20 LM -{• AAl,'} CITY/STATE/ZIPL k—As 3 <br /> CONTRACTOR _ (1 Y 11 �1[• _— PHONES 2,2- t q 2 R '']_ <br /> CONTRACTOR ADDRESS—0 1 �` )r S CITY/STATE/ZIP �Oo• f S�J / <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATEIZIP <br /> LICENSE X C-57 ❑ C-61 ❑ D-09 0 Other NUMBER ZZ EXPIRATION DATE__ <br /> BILLING PARTY: I 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 Number <br /> TYPE OF WORK 5(—New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal CI Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth7.60 ft Excavation 1'2 in diameter ❑ Open Bottom ?;Gravel Pack/Gravel Size*w::in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter b in Thickness/Gauge/ASTM Schad,7 OIX D ❑ Steel JI Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth_ C ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Pilacement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width It Length ft Thick in U Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible Ll Turbine LI 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 /> SIGNED TITLE O-L.- �� DATE 3•s•2a <br /> • <br /> l <br /> s <br /> 3 <br /> QU N <br /> DEPARTMENT USE ONLY Egl�OplyNT�lyj�, <br /> Application Accepted By —� Date rim Area <br /> Grout Inspection By — Date SPEC AL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS /V <br /> PE SC Received Xheck#/>l Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Remitted Service Request# <br /> — v <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />