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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 <�S'�4 �_ Mnahnll('i CITY/ZIP `CScl�lin 9"C J3.2C: rty <br /> D <br /> CROSS STREET c�mobP.I� APIN 22ci 71}bO l PARCEL SIZE CIA b LAND USE APPLICATION# <br /> OWNER NAME am C4_1\l_IT>I 1�� I 1'hM-_ PHONE 10 - l J C; L/ 0+ <br /> OWNER ADDRESS Sayne GhOVP_ CITYISTATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITYISTATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATE/ZIP <br /> LICENSE C-57 C-61 D-09 Other NUMBER EXPIRATION DATE <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)-Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE :rT.Domestic/Private n Irrigation/Agricultural a Industrial r 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 r i Replacement Well o Well Alteration/Modification rl Other <br /> Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings o Geotechnical s of borings <br /> Out-Of-Service Well o Out-Of-Service Well Renewal C Cross-Connection Repair <br /> New Pum Pump Replacement G Pump Repair Ej Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary i 1 Air Rotary o Auger ❑Cable Tool ❑Push Point u Other <br /> Proposed Well Depth ft Excavation in diameter i Open Bottom o Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad n Steel ❑Plastic n Stainless Steel _l Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) Cl Sand Cement sack mix/7 gal water <br /> I Bentonite(20%solids) Other <br /> Grout Placement Method :_ Pumped Free Fall -Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> ii Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ubmersibleo Turbine Other HP jyjjj&Wq Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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��(/'jam'UM ,{•�/}(�' AD�V�•u E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7x697 7 <br /> SIGNED( L' o+ W TITLE d •I'C�� DATE 6 1 —6 11(_ Z 0 4 <br /> rat I PHI PEN', �' <br /> GNAT <br /> �P T M E N T S E N�LJ,YI ,I,��(�,�`y/('���,.1-�{��� <br /> Application Accepted By ate vv Area Employee ID#J�'— 4; " <br /> Grout Inspection By t p Date SPECIAL Well Permit <br /> Pump Inspection By Data ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#I Amount DatePermit/ Invoice# Well ID# <br /> o Info By Remitted Service Re est# <br /> ( 1 <br /> EHD43-06 6111f2019 WELL/PUMP PERMIT <br />