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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 l' Y� , � 10� CITY/ZIP V-1pa 1, 9 ).710/6m <br /> D <br /> CROSS STREET e�1f►MaI}a1/1 _APN '104 -3640 -3S PARCEL SIZE"LQLAND USE APPLICATION# A <br /> OWNER NAME ��► A'Fi er1 /Tam ksolhAN s PHONE <br /> _7 N <br /> OWNER ADDRESS �.0�3p \J WtA\1 _Oe►kST - CIiYISTATF/ZIP7Slfp� <br /> CONTRACTOR eog I I SI��� rLt�(- _ PHONE <br /> 11 22.-19 LPf <br /> CONTRACTOR ADDRESS 119 A I6trs id. CITYISTATE/ZIP malts T�� 61 . 9 S30 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE �C-57 ❑ C-61 U D-09 ❑ Other NUMBER.ILLQQ_10j___ EXPIRATIONDATE_�'3d�2� <br /> BILLING PARTY: I OWNER CONTRACTOR i SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural D Industrial D 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 YcNewWell ❑ Replacement Well ❑ Well Alteration/Modification D Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> 11 Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump D Pump Replacement D Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 'SOC ft Excavation 11 ly in diameter ❑ Open Bottom V Gravel Pack/Gravel Size in diameter <br /> D Conductor Casing in diameter 1 Conductor Casing Depth ft <br /> Well Casing Diameter"_�_ in Thickness/Gauge/ASTM Sched Z00 ❑ Steel 1if;Plastic n Stainless Steel ❑ Other <br /> Grout Seal Depth 2,g 0 ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> XBentonite(20%solids) D Other <br /> Grout Placement Method flyumped ❑ Free Fall ❑ Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller X Pump Contractor D Other <br /> ❑ Concrete Pedestal❑Dimensions:Width It Length ft Thick in ❑ Christy Box D Stove Pipe <br /> PUMP ❑ Submersible[] Turbine ❑ 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 /> MI UM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-766977 <br /> SIGNED DATE -s <br /> O _ <br /> IV <br /> or— <br /> Y <br /> J <br /> 1 IV#j � � 7.1 <br /> U <br /> 15ARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID#�� <br /> Grout Inspection By Date PECIAL Well Permit <br /> Ylump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By _ Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Se Received Chec Amount Permit/Codes Info B Cash Remitted Date Service Re uest# Invoice# Well ID# <br /> 6f 4 7,bs o0 <br /> EHD 43-D6 6111/2019 WELL/PUMP PERMIT <br />