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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.siciov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS L CITY/LPD — <br /> 7 1n D <br /> CROSS STREET , APN ��/ 0 ARCEL SIZE�v- AND USE APPLICATION# o <br /> OWNER NAME ���1�1�j1- 1 .r 1 V'�\F�'i �tV Z(�1/�v� ��' l� -/V/��yWONE `Z���(�- J\ �311U/1 vNi <br /> OWNER ADDRESS ( Cl �r�C+v�� /�� CITY/STATE/ZIP V(,Jky'�-\e_ L A L/5 36, <br /> CONTRACTOR PHONE <br /> i <br /> CONTRACTOR ADDRESS CITY/STATE/ZJP <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 D-09 Other NUMBER EXPIRATION DATE <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE U Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> i i Public Water System <br /> If different Irom Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK iI New Well Replacement Well Well Alteration/Modification Other A YIWIE� y� <br /> AI . <br /> pr�� <br /> i 1 Monitoring Wells) #of wells Soil Boring #ofbodngs <br /> s) #of borings �vel) <br /> Geotechnical 4 <br /> I Out-Of-Service Well Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> New Pump I7 Pump Replacement Pump Repair ❑Raise Well Casing <br /> V <br /> 2U <br /> WELL CONSTRUCTION D ]_ ^�� <br /> Drilling Method i I Mud Rotary Air Rotary Auger Cable Tool Push Point Other Aid.,,'j <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in dianLt gQUIN C <br /> Conductor Casing n diameter / Conductor Casing Depth ft HEAL OU1p0NA4ENT,q NTM <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched �,]Steel Plastic Stainless Steel Other Ep,4,, M <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack m/x/7 gal water ENT <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped I1 Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal i Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible 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 TUE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LA S. <br /> Mlal U HOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS- EASE CALL(209) 3_76�7L _I <br /> SIGNED / TITLE l/ V v 1 �l'i DATE <br /> EP RTMENT USY /( <br /> Application Accepted By ^ Date I tq Area Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date \4 1 WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc ReceivedCheck Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Remitted Service Request# <br /> I <br /> EHD 43-06 6/112019 WELL/PUMP PERMIT <br />