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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 �0 A." U_A CITY/ZIP ZA r�ii <br /> -. O Q 0 /(r� n <br /> CROSS STREET Iii APN 8 Z.S ' L PARCEL SIZE LAND USE APPLICATION# / <br /> OWNER NAME /t LL ��//J� PHONE/ } !` 7 ui <br /> OWNER ADDRESS �/�1� CITY/STATE/ZIP ^� <br /> CONTRACTOR / C su P-"`J ZL/kq PHONE <br /> CONTRACTOR ADDRESS 0 GO CITY/STATE/ZIP <br /> +n / <br /> SUBCONTRACTOR/CONSULTANT PHONE Z—/'.1/L Za <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE oMCL-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER37 7 38-t EXPIRATION DATE <br /> BILLING PARTY: ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDE[ USE ❑ Domestic/Private igation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> S0 If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK Kew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 ud Rj tary ❑ Air Rotary ❑Auger ❑ Cable Tool El Push Point ❑ Other <br /> Proposed Well Depth 4 a ft Excavation LZ in diameter ❑ Open Bottom >erravel Pack/Gravel Size in diameter <br /> ❑ ConductoyCasing in diameter / Conductor Casing Depth_ ft <br /> Well Casing Diameter 6 in Thickness/Gauge/ASTM Sched ❑ Steel Xlastic ❑ Stain ess Steel ❑ Other <br /> Grout Seal Depth 2_5 ft ❑ Neat Cement(94 lb bag/5-10 gal water) >Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method AeRumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By AZriller ❑ Pump Contractor Other 17 <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length Or ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP .RP9Lbmersible❑ 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 8 H UR VANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE Q fes[/ 4, DATE <br /> DEPARTMENT USE ONLY ' JO,q <br /> Application Accepted By ���� v Date }r��d0�0 Area y H�ALNnRQUI qpNAA <br /> Grout Inspection By Iyka I Date 11 Si W@II Per11Tl[TMEI <br /> Pump Inspection By S�• �rtua. �.,./� Date ��'L� /�1D )( WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> pv <br /> COMMENTS C)) -}-c 'fro,.,l1t 130 ��ef fry +n gyl)m�; rMC� o"i PnG10SUlPS. <br /> PE SC Received heck#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> H36,q FO 1y130 <br /> 93 b0 0 �' 1 s ?•0 D <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />