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f <br /> 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 /> a9 so L-�d , y <br /> Joe ADDRESS c J � StrnG r�.M C n 0 .47T f . CmIZIP o <br /> I m <br /> CROSS STREET OAK .54(ca4- APN ` 11� ° D <br /> Pea l 1� (70,27 <br /> ' 9 PARCEL SIZE � } LAND USE APPLICATION# A <br /> OWNER NAME �J-y IO i'1 L Il l /'STC+1 I roc c'/1 0 27 J24/9y //��PHONEI,, 1' ) �+ <br /> OWNER ADDRESS Ij o,, v/ ,� /y f: )�L�� CITYISTATEIZIP l/rro kV'i� ///^�v i (-,A/7G <br /> CONTRACTOR �4cr�GC/ �! PHONE3-7or <br /> /� <br /> CONTRACTOR ADDRESS !0� TY n d U.54(r 111 VOA! CITYISTATE/ZIP �-O1f C-A q 5 X YO <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATE/ZIP <br /> 1 <br /> LICENSE 7'C-57 C-61 D-09 Other NUMBER le T 6O� EXPIRATION DATE <br /> BILLING PARTY: J OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE 'Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> n Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK D New Well Replacement Well Well Alteration/Modification Other <br /> n Monitoring Wells) #of wells Soil Boring(s) #of borings Geotechnical 4 of borings <br /> ❑Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> l New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary /Auger i Cable Tool i Push Point Other <br /> Proposed Well Depth 1 O ft Excavation 4" in diameter -1 Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic I Stainless Steel Other <br /> Grout Seal Depth 30 It ;Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) -Other <br /> Grout Placement Method l Pumped ❑ Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller 0 Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width it Length it 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 THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> INI�M�4/M 4[S/HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED V>t'Y� TITLE O f a`i ff Q M an a.4 w r DATE <br /> PAYMENT <br /> RECEIVE® <br /> N 2 8 2021 <br /> SAN JOAQUIN COUNTY <br /> / ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> DEPARTMENT USF ONLY <br /> Application Accepted By � LJ Date Area ����/ Employee ID# LA. <br /> Grout Inspection By Date I �L SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspecton By Date Constructed Well Depth ft <br /> COMMENTS / .0 lay `/e 7 e c:0: T 111 20 G Q CSorv— :L f <br /> f 0 1 t,IAI I-eG/ ujct S N U ti l l <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well 1D# 1 <br /> Codes In B as Remitted I Se ice Request# <br /> Is D fly 2 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />