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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT i<zca EAST HAZELTON AVENUE-STOCKTON CA 95205-5.232 (209)468-3420 <br /> NON-REFUNDABLE_ PERMIT'R9"9 wYw.sigov.or /eh� `;i`a'IRIwS � �' AR FROM RATE ISSUED <br /> -- /� 1 2 V Y V` 1/1 t�V" CiTl'1Z' ✓ C �_ ✓ 1<— m <br /> /06 ADDRESS --- <br /> C �,J G 7n� 0 <br /> CROSS STREET S e 1(%In e Y APf _ I'(J�� --p"F<;-E I7_E �i AND USE APPLICATION — --- � <br /> - �R b-e c t rt e. T(, � t U_ d—L4 v���5�=� � y <br /> PHON,. I .. <br /> OWNER NAME �j {/�, � ------�-� � - <br /> OWtdE2ADDRESS2qa�.J _�! � ' ' "' GIT1';STATEIP vc � �"J ��� <br /> i�l�L C� -f� + r/� S :Ey) C PHONE . �/J V 1 <br /> 1 CONTRACTOR �j I'd <br /> ` �_.- <br /> CONTRACTORADDRESS � P f _-_. CITYr'STATeit-�lp vy Vty'O� <br /> S U BC ONTRACTORICONSULTANT PHONE <br /> i SUBCONTRACTOR/CONSULTANT ADDRESS NIA CITY/STAT 1ZIP N ! 1 1 /--� C> <br /> LICENSE _ G57 X C-61 _ D-09 _ OtherO2-((-�_—_ NUMBER_�1 WbO EXPIRATIOIJ DATE (•_., <br /> BILLING PARTY: OWNER �CONTRACTOR 7 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391)- Dibromochloropropane(4392) -Arsenic(4393) e% <br /> i 5NTENDED USE omestic/Private - Irrigation/Agricultural - Industrial _ Water Quality Monitoring _ Soil Sampling/Characterization �� <br /> I <br /> _ Public Water System i <br /> If different from Owner. Water System Name Contact Name or Phone Number ! <br /> Type OF WORK -. New Well " Replacement Well : Well Alteration/Modification _ Other <br /> of borings - Geotechnical m of borings <br /> - Monitoring Well(s) #of wells Soil Boring(s) I <br /> _ Out-Of-Servi e Well _ Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pum2 Replacement :: Pump Repair - Raise Well Casing <br /> WELL CONSTRUCTION <br /> D:'illing Method -. Mud Rotary _ Air Rotary - Auger _ Cable Tool Push Point _ Other <br /> I <br /> Proposed Well Depth ft Excavation in diameter - Open Bottom _ Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ! ft <br /> Weil Casing Diameter_ in Thickness/Gauge/ASI'M Sched _ Steel ' Plastic - Stainless Steel a Other <br /> Grout Sea] Depth_ ft Neat Cement(94 lb bagl5-10 gal water) 7 Sand Cement sack mix17 gal water <br /> = Bentonite(20%solids) , Other <br /> Grout Placement Method - Pumped -. Free Fall - Other Retardant I Accelerator(name) <br /> PEDESTAL Installed By - Driller Pump Contractor = Other <br /> _ Concrete Pedestal Dimensions:Width ft Lev ft Thick in _ Christy Box _ Stove Pipe <br /> sl- unn - Submersible- Turbine - Other HP Pump Set ft Standing Water Level ft <br /> I-_-_.- <br /> P <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN i <br /> JOAQUIN C0I1114TY ORDINANCES, ST.ATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> E,7rrtr } z€. TF1 CAL:/.r: F€A ^!5l,'T�; T S r jV eAT r r e :na q; ili i <br /> r A T€i , , '€i AC ORS Tf' E ].it:E'r: E ��:.F t.:"d« s ' "-.i: {fti CC:A,:PL +!'.;: 4 :a-a ,�1. <br /> `AJvRKERS COMPENSATION LAWS. <br /> �NlInlsiift�9 4 p�R A N—E N—T?C� RE-CaHIRED s R Ifs EG IONS -P ;:ASE CALL (209) 953-7597 <br /> SIGNED G �c AO 7✓ 1TLE 56 V✓"r//�Y_�!(A4 DATE �V Com---- <br /> � � <br /> I ' <br /> I <br /> ' 1JIC,47 <br /> hFALT RONMaC�(✓Nr <br /> DEPARTMENT USE ONLY NgRTML <br /> Application Accepted By ����t% Date bodo o Area tj 1q- Ernp <br /> IDS <br /> Grout Inspection By C �1 Date a L: SPECIAL Well Permit <br /> Pump Inspection By C�P�iny �W1e:e 1� .l . Date Il �` tiles_ I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC ReceivedChec Amount Date Permit! Invoice# Well ID# <br /> Codes Info B Cas Remitted AeryAce Request# <br /> $1So <br /> WELL/PUMP PERMIT <br /> d #7 2 ?� <br /> EHD 43-06 6111/2019 <br />