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t <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE P RMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM PfTE ISSUED <br /> _N <br /> JOB ADDRESS cr CITY/ZIP <br /> ' D <br /> CROSS STREET APN PARCEL SIZE/.. x 1 LAND U SE APPLICATION# A <br /> OWNER NAME <br /> QJSGc - PHONEOWNERADDRESS L-4- CITY/STATEIZIP <br /> CONTRACTOR �"'�nE5U L.surkXPaipk �G I\ PH..V(N:✓)/V 7Z�10 l-3�8 <br /> L <br /> q <br /> CONTRACTOR ADDRESS ISIDMAlP( ds/(U`C CIN/STATE2IP f) ypA 64 ^S <br /> twe <br /> IP 26 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATEIZIP <br /> LICENSE X57 D C-61 OD-09 ❑Other NUMEMCiS910-1 EXPIRATION DATE_QZ/3LI121 <br /> BILLING PARTY:❑ OWNER 4ONTRACTOR ❑SUBCONTRACTORICONSULTANT 7 <br /> DOMESTIC WELL SAMPLING:❑General MinerallColiform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural D Industrial ❑Water Quality Monitoring NOlSoilSampling/Characterization <br /> D Public Water System <br /> 8 different from Omer. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Weil ❑Replacement Well ❑Well Alteration/Mnd'Ification ❑Other <br /> ❑Monftoring Wells) #of wells Aoii Boring(s) of borings �;rGeotechnical 7 bo ngs <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump D Pump Replacement D Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool V45ush Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel D Other <br /> Grout Seal Depth !j<Q ft Q Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mW7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method Qooloumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor D Other <br /> ❑Concrete Pedestal DDimenslons: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 /> MINIM IR ADV REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED 7 TITLE DATE �- <br /> tk— <br /> IA <br /> FO <br /> ?0?� <br /> FNT <br /> DE ARTMENT U E O _LIYl < ►� C <br /> Application Accepted By Date Area J "Employee ID# <br /> Grout Inspection By f Date ❑ SPECIAL Well Permit <br /> Pump Inspection By �, Date D WAIVER Received <br /> Soil Boring Inspection By �S�o �eztt,•ffj-wit Date Constructed Well Depth ft <br /> COMMENTS _Q11 � L� l�� Z4D"c_S=lq <br /> PE Sc Received Chec—�` AmountPermitf Invoice# Well ID# <br /> Codes Info B emitte De Service Re uest# <br /> 0 <br /> EHO 4306 6/112019 WELL AIUMP PERMIT <br />