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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 I jY f_ CITY/ZIP Dar Q f lU (0 m <br /> CROSS STREET Fyn e APIN dO V w©I I PARCEL SIZE I,d' LAND US4APPLICATION[fF1 <br /> � A <br /> P NE I �Q y <br /> OWNER NAME �� I � G���j <br /> TOWNER ADDRESS �� A VCCITY/STA E/ZIP_ ` v <br /> CONTRACTORv v" f�,� L t ' ` `� PHON I )l <br /> CONTRACTOR ADDRESS V "V �t� CITY/TATEW6 C0 /�V <br /> SUBCONTRACTOR/CONSULTANT J PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS ` CITY/STATiEIZIOP <br /> LICENSE _ C-57 X C-61 - D-09 Other NUMBER alt"," ) EXPIRATION DATE_ <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 - 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 U Replacement Well U Well Alteration/Modification _ Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings - Geotechnical #of borings <br /> _ Out-Of-Service Well j Out-Of-Service Well Renewal Cross-Connection Rep /�AYNjEN� <br /> A j <br /> - New Pump Pump Replacement c Pump Repair L Raise Well Casing f� <br /> WELL CONSTRUC11ON ~C'V�D C� <br /> 'Drilling Method _ Mud Rotary Li Air Rotary L Auger _ Cable Tool Push Point _ Other <br /> Proposed Well Depth ft Excavation in diameter ! Open Bottom L Gravel Pack! a el U, n _in diameter <br /> _ Conductor Casing in diameter / Conductor Casing Depth ft BAN JOAQUIN <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched J Steel J Plastic _ StNt RoNhj��TYNTY ul <br /> Grout Seal Depth ft D Neat Cement(94 Ib bag/5-10 gal water) n Sand Cement DEPART A aL rnW7 gal water <br /> - Bentonite(20%solids) U Other <br /> Grout Placement Method - Pumped 5 Free Fall r1 Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By = Driller ❑ Pump Contractor - Other <br /> Concrete Pedestal LDimensions:Width ft Len th ft Thic in _ Christy Box _ Stove Pipe <br /> PUMP Submersible- Turbine n Other HP i Pump Set LVft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, PTATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH T CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION <br /> MINIMUM 48 H fA& CE NOTICE REQUIRED FqR INSPECTIONS -PLEASE CALL (20 "3-7697, <br /> SIGNED TITLEROA r 1 IX// I DATE v� <br /> I <br /> c <br /> I I <br /> DEPARTMENT USE ONLY p <br /> Application Accepted By Date /d dada Area �1 C/ Employee ID# F <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By kra,.a:c ca ViRM�a � Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Receivedec Amount Permit/ <br /> Codes Info B _Qk� s Remitted Date Service Request# Invoice# Well ID# <br /> y3$F os-o 477 <br /> EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />