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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 / Q �y(�Q� /Z� CITY/ZIP 5y/_141 m <br /> CROSS STREET /�'��A� -.. APN /L O�_M1, PARCEL SIZE I'll—LAND USE APPLICATION# / y►? <br /> OWNER NAME � } � f� PHHONN�p p� U) <br /> OWNER ADDRESS �f` CITY/STATE/ZIP r7/ !�AV_4 J/ ` / <br /> CONTRACTOR _ _ / PHONE' <br /> CONTRACTOR ADDRESS © (/v�� /�� CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT J� j1/ PHONE <br /> SUBCONTRACTORRICONSULTANT ADDRESS CITY/STATE/ZIP <br /> ,�//� <br /> LICENSE 57 I�i f I D-09 ❑ Other NUMBER_� JULa EXPIRATION DATE_-_ <br /> BILLING PARTY: 'OWNER I CONTRACTOR SUBCONTRACTOR/CONSULTANT w <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) ^%.Ou <br /> INTENDED USEomestic/Private F1Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring L1 Soil Sampling/CharacterseftI <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well ❑ Replacement Well ❑ Well Alteration/Modification 11 Other SqN J <br /> #of borings 1�JAf <br /> Monitoring Well(s) #of wells ❑ Soil Boring(s) CI Geotechnical_ _ ��M�. <br /> ❑ Out-Of-Service Well r.] Out-Of-Service Well Renewal CI Cross-Connection Repair HATH p �NT,qL <br /> 11 New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing New <br /> WELL CONSTRUCTION <br /> Drilling Method Wud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool Cl Push Point ❑ Other <br /> Proposed Well Depth 20 ft Excavation — 12- in diameter ❑ Open Bottom Gravel Pack/Gravel Sizeinin diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched CL- Zaire ❑ SteelI-WPlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth_ e�&Dft ❑ Neat Cement(94 lb bag15-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> D entonite(20%solids) ❑ Other <br /> Grout Placement Method 11 Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> rI Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> rPump )dSubmersible0 Turbine ❑ Other HPF Pump Set ft Standing Wat( - 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 /> MINI ;M;CE <br /> NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 953-7 97 <br /> SIGNED ��- _ TITLE //� GC DATE 1D <br /> Vt <br /> D <br /> KA L <br /> D E ARTMENT U S E N L Y <br /> Application Accepted By Date /0 Area 14V Employee ID# 0 <br /> Grout Inspection By Date (OZZ.Ah'.9- SP CIAL Well Permit <br /> Pump Inspection By S�o (ern aMincti , Date 1 �1. t7 _ WAIVER Received �� <br /> Soil Boring Ins <br /> coon By Date C nstructed Well Depth ft <br /> COMMENTS Q 3 Ait-(t �__ _ <br /> I <br /> PE SC Received Ch Amount Date Permit/ Invoice# "1fVell lD# <br /> Codes Into By, Cash Remitted Service Re uest# <br /> 0 40 1 (D 01 <br /> _irk -_»� !a PO04 O <br /> I �l <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />