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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.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS '•/�oC PJ � CITY/ZIP ''ail/�—/�/ ; �7 rn <br /> CROSS STREET S APh v /, ,/ PARCEL SIZE •"? LAND USE APPLICATION# o <br /> m <br /> OWNER NAME PHONE <n <br /> OWNER ADDRESS A C CITY/STATE/ZIP 2�� 7/2- <br /> CONTRACTOR /IIf/ It.J� � t��—f PHONE <br /> CONTRACTOR ADDRESS �G—(1 �f�� CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS — CITY/STATE/ZIP <br /> LICENSE 57 C-61 D-09 _ Other NUMBER t EXPIRATION DATE <br /> BILLING PARTY: OWNER CONTRACTOR _ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391)1 Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE "-Vmestic/Private L 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 _ New Well _ Replacement Well Well Alteration/Modification _ Other <br /> _ Monitoring Well(s) #of wells __ Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Wump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION 11 <br /> Drilling Method _. Mud Rotary _ Air Rotary _ Auger Cable Tool Push Point _ Other <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 /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft _ 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 _. Pumped _ 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 ubmersible_ Turbine _ Other HP Pump Set__,g2g�; _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 /> MI HO NCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953y-/Zj¢6/J97 <br /> SIGNED TITLE DATE ��[O! <br /> O <br /> 1 tL <br /> rvq <br /> if I <br /> JO <br /> HAW <br /> O N <br /> A T <br /> DEPARTMENT USE ONLY <br /> / L/ 0 <br /> Application Accepted By ��' ��/ Date /a a�� Area / Employee ID# �� <br /> Grout Inspection By Date L SPECIAL Well Permit <br /> Pump Inspection By ary�.S�� GUt r l�,yr.l� Date lj 1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received h_ecjjP Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> L 3 1 0O U5 110D Z 4:7 )T-9 - 20 0 P 0�)-A <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />