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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONIMENTACHEALTH 0EPAPT14EM-F I 86a EA-'7 HAZELTON AVENUE-STOCKTON CA 96205-6232 (209)468-3420 <br /> NON-REFUNDABL'E PERMIT www.sigov,oEq <br /> EXPORE 1 YEAR FROM DATE ISSUED <br /> M <br /> �Jos AnDRE$S > <br /> CROSS STREET CC41 I(>y rt AP d,?5•o60aq PARCELSUeE 04• 1 LAND USE APPLICATION <br /> &1 <br /> m 9) 4 X <br /> QVINE"i NAmE <br /> 3-2-n <br /> cin Li fVuMcwtt --.— 7 <br /> OWNER ADORE I td S T A:�T%E�111 P <br /> Ss <br /> T� PHONE <br /> 'CONTRACTOR <br /> kn <br /> -F <br /> Iq Tv (( rC4 <br /> CONTRACTor,ADDRESS CITylSTAT <br /> CONS�LTAINTI" PF,CNE IV <br /> !,�UBCONTHAGTOR/ ----------- <br /> SUBCONTRACTORICONSULTANT ADDRESS CITYlSTA.TE/-,IP1-M <br /> ,6 <br /> i LICENSE C-57 �C-61 D-09 Othei R 2-7(mEXPIRATION DATE <br /> 1 BILLING PAR-,e: OWNER YCONTRACTOR SUSCONTRACTOFJCONSULTANT <br /> 'DOMES-11C WELL SAMPLING: --General Mineral/Coliform Bacteria(4391)= Dibromcchloropropane(4392)- Arsenic(4393) <br /> jK,TrNDEDUSE 2<DornesiiclPrivate - Irrigation./Agricultural - Industrial Water Quality P.4onitoring _ Soil Sampling/Characterization <br /> Public Water System <br /> If different from 0%vner. Water System Name contact Name or Phone Number <br /> New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells 7 Soil Boring(s)_ #or borings Geotechnical I of borings <br /> Out-Of-Service Well •Pump Repair Out-Of-Service Well Renewal Cross-Connection Repair <br /> New P11111L _ Pump Replacement Raise Well Casinq _ <br /> )_ :] <br /> 4�1 LL <br /> CONSTRUCTION <br /> Drilling Method - Mud Rotary Air Rotary - Auger - Cable Tool. Pusf;Point Other__ <br /> Pt-oposed Well Depth­ ft Excavation in diameter Open Bottom -- Gravel Pack/Gravel Size in diameter' <br /> Conductor Casing in diameter I Conductor Casing Depth <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel - Plastic - Stainless Steel 'Lj Other— I IW— <br /> r <br /> Grout Seal Depth ft 7 Neat Cement(94 lb bag/5-?0 gal water) .7 Send Cement Sack mix/7 gal wateI <br /> Bentonite(20%solids) -- Other_ <br /> _Grout PI acement Method Pumped -7 Free Fall 7, Other Retardant I Accelerator(name) <br /> PEOF$TAL Installed By -- Driller Pump Contractor = Other <br /> Concrete Pedestal;-Dimensions:Width ft Length It Thick in Christy Box - Stqvc�Pipe <br /> Submergible- Turbine 7 Other HP Pump Set ft Standing Water Level <br /> P <br /> P Ua <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 REGULATION& I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> ,.'URRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIAACE w1rTH A'­' <br /> AfORKERS CWAPENSATION LAWS. <br /> lNie UM 48 H A D V ANC E TICE REQUIRED FOR INSPE-CTIONS - PLEASE CALL(209) 953-7697 <br /> DATE <br /> SIGNED TITLE <br /> ri <br /> J F <br /> h I <br /> T— <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Ji ao2b Area Employee lD# F R <br /> Grout Inspection By Date El SPECIAL Well Permit <br /> Pump Inspection By RLAA V v,'t, Date [*1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS WI k;y% pvOiC 0014t-w- 01;S+7f1f ;n5lde. CJ)y L,,ifS <br /> PE SC Received �e <br /> _Cqh ck Amount v <br /> Date Permit/ Invoice# Well ID# <br /> Codes Info y- Remitted Service Reques # <br /> (2-F P 3/Z,/,3. <br /> EHD 43-06 6111/2019 WELL/PUMP PERMIT <br />