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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 /> �y( L-454-6, J <br /> JOB ADDRESS 2,(J 7 00 JK.l�1 i CITY/ZIP 1 Gy Z; m <br /> n 1 7� D <br /> CROSS STREET m n^ I'7 r� AP/N� 91 Xaoa PARCEL SIZE—It)L LAND USE APPLICATION# p <br /> OWNER NAME •Y wt/Aw I"7u,� �i PHONE y <br /> OWNER ADDRESS �C'� r�V7•�S4)5141 CITY/STATE/ZIP C4L� <br /> CONTRACTOR J `J I/\ �f 5;lftA e/r`.I�G7 i-L-, PHONE `/—�{A. I�j` —�J/(� <br /> CONTRACTOR ADDRESS Ip /+-( I w r(9P,C �/sbW^' - 7�C CITY/STATE/ZIP aaIId <br /> SUBCONTRACTOR/CONSULTANT �l(,I•PM !�nom)� /'(,C1 -L/1_/ PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS ( ( V r (�G N�1.1.t?(1//I CITY/STATE/ZIP <br /> LICENSE kZL Z <br /> C-57 C-61 D-09 Other NUMBER T U EXPIRATION DATE ..3/3( 12,0 1-2— <br /> BILLING <br /> ZBILLING PARTY: OWNER <CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring 1.. 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 I Replacement Well !Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells XSoil Borings) 6 u of borings X Geotechnical�_#of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary -<uger Cable Tool Push Point Other <br /> Proposed Weil Depth Zn <br /> '5 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 • Other <br /> Grout Seal Depth?, )t: O ft ?(Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped, Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box - 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)J953-7697 <br /> SIGNED — TITLE �(tO K� 1�<e DATE <br /> pgY�F <br /> FCF�V�l <br /> V � O <br /> oc,),y ?�2O <br /> pqR c ke <br /> T <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date /)b3 o.0 U Area S Employee ID# A I <br /> Grout Inspection By ?ct Date 1\ SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received he Amount at Permit/ Invoice# Well ID# <br /> Codes Info Alenash Remitted Service Request# <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />