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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 PERMIIT7 wwwsjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS !/ P,.Z ✓ CITYIZIP C m <br /> CROSS STREET APN G1fq-Z4a,24V '-/ <br /> J C.yPARCEL Slz LAND USE APPLICATION# o <br /> OWNER NAME (� _Lr(, IrPHONE <br /> •`+ / �J <br /> T �t./�6� /�•JPy�� m <br /> OWNER ADDRESS S4�I get CITY/STATEIZIP Z-15 <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATEOP <br /> LICENSE LI C-57 [i C-61 C D-09 CI Other NUMBER EXPIRATION DATE <br /> BILLING PARTY: D OWNER D CONTRACTOR D SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391),:]Dibromochloropropane(4392)i i Arsenic(4393) <br /> INTENDED USE Domestic/Private D Irrigation/Agricultural C Industrial D Water Quality Monitoring n Soil Sampling/Characterization <br /> iI Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK i7 New Well Replacement Well D Well Alteration/Modification G Other <br /> o Monitoring Well(s) #of wells L Soil Boring(s) #of borings 17 Geotechnical #of borings <br /> Out-Of-Service Well L Out-Of-Service Well Renewal D Cross-Connection Repair <br /> D New Pump D Pump Replacement D Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rotary li Air Rotary G Auger Cable Tool Push Point D Other <br /> Proposed Well Depth ft Excavation in diameter D Open Bottom -1 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 D Stainless Steel D Other <br /> Grout Seal Depth ft t Neat Cement(94 lb bag/5.10 gal water) i Sand Cement sack mixf7 gal water <br /> D Bentonite(20%solids) i_I Other <br /> Grout Placement Method D Pumped D Free Fall D Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller D Pump Contractor Other <br /> D Concrete Pedestal GDimensions:Width ft Length ft Thick in C Christy Box D Stove Pipe <br /> PUMP D Submersible0 Turbine CI 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 /> MINIMU HOIyIEAD eCE E IRED FOR INSPECTIONS-PLEASE CALL(209)9`53-77697 <br /> SIGNED G 1 G'if®�` •-?��N TITLE «,KIi�lr DATE <br /> CYM�NT <br /> 3 a 2p�0 <br /> Q/J//V T C <br /> N (l�TY <br /> SPARO <br /> D JdAITAENT SE N L Y <br /> Application Accepted By _ Date Date a C Area Employee <br /> Grout Inspection By CI PECIAL Well Permit <br /> Pump Inspection By Oe^M'N .S W Lam, Date 1417 ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth it <br /> COMMENTS <br /> PE SC Received Chec Amount Permitl <br /> Code Info S 1 emitted Date Service Re ue # Invoice# Well ID# <br /> YW VMU <br /> EHD 43-06 6/112018 WELL/PUMP PERMIT <br />