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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.s c�ov_or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �}'/ CITY/ZIP <br /> CROSS STREET ) J� OjQ R L SIZE LAND USE A`PPPLICCA.TIONN## <br /> OWNER NAME /,l L-17G/L/\/L/ PHONE PO <br /> OWNER ADDRESS L J ` � �.{,y/r_fiOL CITY/STATE/ZIP �f/� 404 <br /> 5;�cfy/���—:;I <br /> el <br /> CONTRACTOR / PHONE <br /> ��J / /���/`✓ U /' <br /> CONTRACTOR ADDRESS ZZ42 ITY/STATE/ZIP <br /> c <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSUL`TA�N,T,.ADDRESS CITY/STATEIZIP <br /> LICENSE *C-57 -61 I I D-09 a Other NUMBER EXPIRATION DATE Z <br /> BILLING PARTY: 'yet-61 <br /> OWNER CONTRACTOR - SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE omestic/Private 0 Irrigation/Agricultural CI Industrial D Water Quality Monitoring 0 Soil Sampling/Characterization <br /> I Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well I Replacement Well Well Alteration/Modification 0 Other <br /> Monitoring Well(s) #of wells SoilBoring(s) #of borings D Geotechnical #of borings <br /> Out-Of-Service Well i Out-Of-Service Well Renewal D Cross-Connection Repair <br /> JANew Pump D Pump Replacement LI Pump Repair ❑Raise Well Casing <br /> WELL CONSTR TION <br /> Drilling Method VMud Rotary Air Rotary -1 Auger i=l Cable Tool ❑Push Point Other 44 <br /> Proposed Well/DepthZW It Excavation 12– in diameter c Open Bottom /Gravel Pack/Gravel Size_.2V in diameter <br /> ConductorCasing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad Steel Plastic D Stainless Steel eI Other <br /> Grout Seal Depth IX ft ❑Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mixl7 gal water <br /> Bentonite(20%solids) Li Other <br /> Grout Placement Method umped ❑Free Fall 0 Other D Retardant I Accelerator(name) <br /> PEDESTAL Installed By ❑Drillerump Contractor D Other <br /> Concrete Pedestal r Di ensions:Width ft Length It Thick in D Christy Box ❑Stove Pipe <br /> PUMP ubmersible❑Turbine D Other HP Pump Set ft Standing Water Level <br /> IHEREBY 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 JAM IN COMPLIANCE <br /> �/WITH ALL <br /> WORKERS C EN TION WS. � �7i <br /> Nil U1 NOTICE REQUIRED FO NSPECTIONS- L A CALL(209)953- 97 <br /> SIGNED TITLE DATE <br /> V1 <br /> a pgY�FNT <br /> CFjV <br /> 102019 <br /> COIJ <br /> T M E N T U O /L �EpAR Pit <br /> Application Accepted By 4b&12Date Q C Area Employee ID#� <br /> Grout Inspection By Date 2 PECIAL Well Permit <br /> Pump Inspection B VqtAdsu 1 Date �JV'2,61* Li WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#1 Amount Permit/Codes Igo B Cash miffed Date Service Request# Invoice# Well ID# <br /> L t)lif 7t/ <br /> WELL/PUMP PERMIT <br /> �v <br />