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r <br /> r � <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 t wWW.S ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> ` <br /> JOB ADDRESS CITYIZIP ` ���� m <br /> ioe, rrl7-/3t� 9 A <br /> CROSS STREET APN PARCEL <br /> SIZE LAND USE APPLICATION# o <br /> M <br /> OWNER NAME ( PPONE w <br /> 14 ' �• ^�- <br /> OWNER ADDRESS CITY/STATE/ZIPS '?J'3 <br /> CONTRACTORr^� //�� •'•• PHONE <br /> CONTRACTOR ADDRESS b V CITY/STATE/ZIP144 U <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE VIC-57 0 C-61 ❑ D-09 ❑ Other NUMBER 74!�2�3 EXPIRATION DATE <br /> BILLING PARTY: C OWNERONTRACTOR f1 SUBCONTRACTOR/CONSULTANT!' <br /> DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑ Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private a Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring r Soil Sampling/Characterization <br /> 7 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ii New Well L Replacement Well a Well Alteration/Modification L Other <br /> i. s 9 of borings� Monitoring Well(s) #of wells G Soil Boring #of borings g - Geotechnical <br /> ❑ Out-Of-Service Well ❑ Of-Service Well Renewal Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method C Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point -1 Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom J Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched C Steel I.7 Plastic ❑ Stainless Steel L Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) -1 Sand Cement sack mix/7 gal water <br /> F1 Bentonite(20%solids) Other <br /> Grout Placement Method L Pumped I I Free Fall L Other a Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 0 Pump Contractor E Other <br /> u Concrete Pedestal!JDimensions:Width ft Length ft Thick in u Christy Box L Stove Pipe <br /> PUMP ❑ Submersible l- urbine fl Other 7 HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERT THAT I PR ARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN CO ORDIN CE ST E LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT CTIVE H T E LIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS C4 <br /> ENSATI LA S. <br /> 8 U E NOTICE REQUIRED FO SPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLEDATE <br /> it 411 <br /> 10 <br /> E FNT <br /> l vF6 <br /> 0 23 2020 <br /> A T NN 01 N <br /> R <br /> ll DEPARTMENT USIE ONLY <br /> Application Accepted By l� Date L3 �' Area S Employee ID# DA <br /> Grout Inspection By Date / ❑ SPECIAL Well Permit <br /> Pump Inspection By �rtw\Lt 5 i o (a&rj,, Date b LV�_tp ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received < heck Amount Permit/ <br /> Codes Info B s Remitted Date Service Request# Invoice# Well ID# <br /> 3Ba Oso #77 23 20 0 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />