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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 m .s ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> JOB ADDRESS 1 CITY/ZIP m <br /> l �jJ �,_ D <br /> CROSS STREET L APN Di2S O /OO7 PARCEL S,_ -7 &) LAND USE APPLICATION# <br /> OWNER NAME <br /> Vd /V� SJ PHONE O�3 - �[// <br /> 7 U) <br /> OWNER ADDRESS /L� CITY/STATE/ZIP <br /> _S: 3' l/ <br /> CONTRACTOR /<`'�� l/✓�il� PHONE <br /> //,(��f �` �/7 ��J <br /> CONTRACTOR ADDRESS '— CITY/STATE/ZIP <br /> 1 � <br /> SUBCONTRACTOR/CONSULTANT �� ` `'�� PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> (� <br /> LICENSE `-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER-3-2-230 EXPIRATION DATE <br /> BILLING PART:': _1 OWNER D CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: I_! eral Mineral/Coliform Bacteria (4391) r Dibromochloropropane (4392) ❑Arsenic(4393) <br /> INTENDED USE W ovate X 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 LTyVeW Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other 7' <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair SEP 1 <br /> 201, <br /> ><w Pump ❑ Pum Replacement 11Pump Repair 11Raise Well Casin C p <br /> WELL CONSTRUCTION SAN JOAQUIN C <br /> Drilling Method,<Mud Rotary ElAir Rotary ❑ Auger LlCable Tool ❑ Push Point ❑ Other Olullwo <br /> O UN <br /> Proposed Well Depth4YOft Excavation L` in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size tj DEPA <br /> ❑ Conducto Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM SchedZ c� ❑ Steel lastic 11 Stainless Steel —1 Other <br /> Grout Seal Depth .W ft ❑ Neat Cement(94 lb bag/5-10 gal water) and Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method>fPumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP A 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 THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMYNI 48 OU ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE DATE <br /> NA <br /> 1>1 <br /> C-t I <br /> DEPARTMENT USE ONLY <br /> Application Accepted By � �1� Date 1FIdOa0 Area / Employee ID#DA <br /> Grcut Inspection By DateI LzDZ� ❑ SPECIALWell Permit <br /> \ <br /> Pump Inspection By ���.t�(r�C7 �r t�� �w;L Date \jk1\\'14v- WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth 33 _ft <br /> COMMENTSOc.IVff ISSu'PC,4 4. lue 4D .I +4Pr jjr; 114 ln�r/� h be IDOL f-I -o e,otY✓/C� <br /> R✓1GJO .56-6Ohay4ei� <br /> PE Sc ReceivedCheck Amount Permit/ <br /> Codes Info B ash Remitted Date Service Request# Invoice# Well ID# <br /> "Lido <br /> 38� o?) Ise 3 <br /> EHD 43-06 6/18/2019 WELL/PUMP PERMIT <br />