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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.s Ov.or /g ehd_ _ ,�E�X,�PIRE/S 1 YEAR FROM DATE ISSUED_ <br />JOB ADDRESS 7 �• v �U �O CITYIZIP T12A 1 / `•+J 17 y <br />CROSS STREET tlJ 1�1�,' y l-/0�-C..W�J N/ )f--` ' %���.�r�y" PARCEL SIZE <br />p 21rrfu LAND USE APPLICATIONy7# „ p <br />OWNER NAME 612 0 AAn) A r6 944 U e-- (4-myi Zmgo' "CP"' PHONE o— .2 'Awl <br />+v�G� H <br />OWNER ADDRESS 1710 <br />010 / �y771 ql u CITYISTATE/ZIP 15`""4 /"rh/,,A �-c � lT <br />CONTRACTOR � rrL(/I,*6C—KU)4L- !1 nA/JV �•�Wn3 PHONE 4V ^ 31.� ! �7J �r <br />CONTRACTOR ADDRESS 3� --9 1 JV :/ U 5 T AI � V LV Or CITU/S AmaIP I 4 L 1 " Cf 5 g/ <br />SUBCONTRACTOR/CONSULTANT \(#W j) A•2�t'Z���/yNJ��//��Nc . ��. ";, PHONE2L'g— 1105 <br />SUBCONTRACTOR/CONSULTANT ADDRESS II.33 j3u L&yyi_5 � ITY/STTA�TE/ZIP a i' �4/36/Z07-7— <br />BILLING <br />A� 'n <br />LICENSE (C-57 (i C-6>1 II D-09 LI Other NUMBER V0 /y EXPIRATION DATE 36/ Lam'7'Z <br />BILLING PARTY: ❑ OWNER YQONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (43y) ❑ Arsenic (4393) <br />INTENDED USE i Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial L Water Quality Monitoring Aoil Sampling/Characterization <br />I Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK i New Well i I Replacement Well I I Well AReration/Modification I Other Od <br />I Monitoring Well(s) # of wells n Soil Boring(s) # of borings X Geotechnical ZA. <br /># of borings <br />i Out -Of -Service Well U Out -Of -Service Well Renewal Cross -Connection Repair <br />I New Pump I Pump Reolacement ❑ PumD Repair u Raise Well Casino <br />Drilling Method 7 Mud Rotary 1 Air Rotary )(Auger � Cable Tool 7 Push Point ❑ Other <br />Proposed Vd l Depth 1,7 Excavation 10 /1 in diameter ❑ Open Bottom CI Gravel Pack/Gravel Size in diameter <br />13Ir2) 1;r6t i Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter in Thickness/ au a/ASTM Schad F1Steel LlPlastic r Stainless Steel j Other <br />Grout Seal Depth RL ft AN.at Cement (94 Ib bag/5-10 gal water) I I Sand Cement sack mix/7 gal water <br />i Bentonite (20% solids) n Other of - <br />Grout Placement Method!Xumped Free Fall k0ther P9 JhW Accelerator (name) <br />PEDEST Installed By ❑ Driller ❑ Pump Contractor i Other <br />Concrete Pedestal F Dimensions: Width It Length It Thick in ❑ Christy Box C Stove Pipe <br />PUMP 1 Submersibles 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 />MINIMUM 48 HOU VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95 76 7 <br />SIGNED41 TITLE e9,Aj ' �^ L�`/R-- DATE -)��`Q <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />PE <br />Info <br />D E MAT o 32 T USE �N�� I Area 1 Employee ID# PA <br />ale '2 El SPECIAL Well Permit <br />Dale ❑ WAIVER Received <br />Date <br />Remitted _ Date <br />Constructed Well Depth ft <br />Invoice # I Well ID# <br />EHD 43-06 6/11/2019 ; WELL (PUMP PERMIT <br />