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WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDAB E PERMIT WWW.S' ov.or /ehd EXPI ES 1 YEAR FROM DATE ISSUED <br /> n <br /> JOB ADDRESS 22 + 1 CITY/ZIP=T� ) 3 OL JOB <br /> CROSS STREET duncom'� PrrV APN � �^� PARCELsizl 11S8LANDUSE APPLICATION# A <br /> w <br /> (OWNER NAME PHONE�/� (O1� /, <, <br /> OWNER ADDRESS`3 I I �' CITY/STATE (�f v J l/`'1 u� <br /> ! j L r/) �n �/I �� ted- � PHONE ✓ oalb (\� <br /> CONTRACTOR l)` j71 <br /> CONTRACTOR ADDRESS 6 o 1 r CITY/STATEIZI l <br /> SUBCONTRACTOR/CONSULTANT r IV PHONE IV I fl <br /> SUBCONTRACTOR/CONSULTANT ADDRESS )-A CITY/STATE/ZIP N 1 V <br /> LICENSE _ C-57 /" C-61 _ D-09 Other 07- NUMBER4)-1 "" t (gV EXPIRATION DATE f ✓ 1'2)b <br /> BILLING PARTY: OWNER CONTRACTOR 1 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 _ 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 L Replacement Well a Well Alteration/Modification _ Other_ <br /> f borings ro <br /> - Monitoring Well(s) #of wells F Soil Boring(s) #o - Geotec � c�onngs <br /> _ Out-Of-Service Well u ut-Of-Service Well Renewal LI Cross-Connection Repair `�/CC --11 <br /> _ New Pump ❑ Pump Replacement Pump Repair C Raise Well Casing /1,. <br /> WELL CONSTRUCTION 2020 (15 <br /> Drilling Method _ Mud Rotary a Air Rotary L2 Auger _ Cable Tool L Push Point _ Other SAN jr),/zN <br /> Proposed Well Depth_ ft Excavation in diameter -j Open Bottom Gra*640§, O)% in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft EPA.R7-MEN-r <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched j Steel Li Plastic _ Stainless Steel u Other <br /> Grout Seal Depth ft n Neat Cement(94 lb bag/5-10 gat water) -I Sand Cement sack mix/7 gal water <br /> = Bentonite(20%solids) 7 Other -� <br /> `Grout Placement Method - Pumped n Free Fall F Other F Retardant/Accelerator(name) <br /> PEDESTAL Installed By = Driller D Pump Contractor Other <br /> Concrete Pedestal LDimensions:Width It Length it Thick in _ Christy Box ❑ Stove Pipe S <br /> PUMP X Submersible- Turbine n Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CEIRTIFY 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 /> --MffqfM`UR>48 HOUR AD NCE NOTICE REQUIRED FORNSPECTI®NS�j PLEASE CALL (2Q9) 53gp,-7�697 <br /> SIGNED (TLE �� ✓��` DATE �i ✓-5 <br /> 1 T/ <br /> �( J <br /> V <br /> O <br /> I <br /> DEPARTMENT USE ONLY p <br /> Application Accepted By � �-L Date 7 /y O� Area E qcl Employee ID# FR <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By P":Sio Date ` 12.91 wtv ❑ WAIVER Received <br /> Soil Boning Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received hec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By ash Remitted Service Request# <br /> 938'0 Oso o *T� • I DO <br /> EHD 43-06 6/11/2019 WELL JPUMP PERMIT <br />