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NON -REFUNDABLE PERMIT <br /> <br />www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CROSS STREET C ( APN 0 <br />OWNER NAME <br /> F 1 ,\J II F lo <br />c <br />PARCEL SIZE W 42-(,' LAND USE APPLICATION ft <br />PHONE <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART1VENT 1868 EAST HAZELTON AVENUE - STOCKTON CA MOS -6232 (209)468-3420 <br />OWNER ADDRESS F. CI e . <br />1)4(.1(4 trl 4_1 <br />CONTRACTOR ADDRESS f> i &>c u <br />SUBCONTRACTOR/CONSULTANT irk I <br />CITY/STATE/ZIP <br />PHONE 2 <br />L') "I <br />CrYISTATEIZIP <br />PitLe (Let 1 <br />PHONE <br />CONTRACTOR <br />SUBCONTRACTOR/CONSULTANT ADDRESS C16.111E74 <br />LICENSE )(C-57 0 C-61 0-09 E Other <br />BILLING PARTY: 11 OWNER <br />DOMESTIC WELL SAMPLING::pi General Mineral/Coliform Bacteria (4391)X0ibromochloropropane (4392) r-i Arsenic (4393) <br /> <br />INTENDED USE A Domestic/Private D Irrigaton/Agricultural U Industrial U Water Quality Monitoring 0 Soil Sampling/Characterization <br /> <br />D Public Water System <br />If different from C‘kner, Water System Name Contact Name or Phone Number <br />ifierfilmA ,?.. <br />TYPE OF WORK X New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other 00 <br />fl Monitoring Well(s) # of wells 0 Soil Boring(s) 9 of boiings n Geotechnical 9 of borings <br />frfil40 <br />U Out.Or-Service Well a Li Out-Of-Service Well Renewal D Cross-nnectkon Repair <br />0 Raise Well Casing <br />i 2y <br />CI New Pump 0 Pump Replacement 0 Pump Repair <br />WELL CONSTRUCTION <br />46"111 j0,1 Qu1/4 <br />Drilling Method A Mud tory <br />0 ft <br />, 0 Air Rotary 0 Auger 4 At ,Cable Tool 0 Rush Point 0 Other 0? <br />Proposed Well Dept ) Excavation k .1.— in diameter r3 Open Bottom XGravel Pack/Gravel Size in diameter <br />44/76,1//6)0„4/04/7), . 0...,_ 44 <br />17 ConducTir Casing in diameter / Conductor Casin Depth ft <br />lu°A1,4?7,47/v7. <br />Well Casing Diameter ki.; in Thickness/Gauge/ASTM Sche ) CI Steel )(Plastic n Stainless Steel Cl Other <br />Grout Seat Depth ft 0 Neat Cement (94 lb bag/5-10 gal water) 0 Sand Cement sack mix17 gal water <br />X;Be rte. (2096 solids) U Other <br />Grout Placement MethZiaA Pumped 11 Free Fall 0 Other <br />ft Thick In Li Christy Box Li Stove Pipe <br />!UM LI Submersible 0 Turbine 0 Other HP Pump Set ft Standing Water Level <br /> 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 />SIGNED <br />11-.CE NOTICE REQUIRED FOR It'PEOTQUIS - PLEASE CALL (209) 95?-1697 0, . •.\ <br />TITLE D DATE loigt) 0/- t- <br />NUMBER !RATION DATE <br />CONTRACTOR 11 SUBCONTRACTOR/CONSULTANT <br />0 Retardant / Accelerator (name) <br />PEDESTAL Installed By D Driller damp Contractor D Other <br />U Concrete Pedestal 0 Dimensions. Width ft Length <br />to <br />IrLE2,04RTMENT U E ONLY <br />G/ Date 2-5 W <br />It)• tc <br />Date <br />Z / <br />A rea 'T -r Employee ID# <br />) <br />/.....PECIAL Well Permit <br />[7 WAIVER Received <br />Celttstrueted Well,Depth <br />--- it'-•/1- _5/--, C' 07g ,=f- I 3 C ' <br />rc,-Tt <br />ft <br />11.0 cAd:, <br />1'6 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Date <br />Soil Boring InspectionN Date <br />COMMENTS 14.4/— /V/.e A act ,f24 ict <br />2C0 <br />PE <br />Codes <br />SC <br />Info <br />le <br />Receive Check*, Amount <br />Remitted Date , ‘ , ,,_ <br />Permit/ <br />. Invoice # Well ID* <br />4.31,1, 1 0 . 1/!,--7-5- IA, <br />Mot R.eq stifc <br />ini Wi41 <br />Lt. 3 i t ifir i ii-i; 9No t;411 <br />4 viz izA 7-0 AZ, - <br />I „V <br />EHO 43-06 6/11/2019 WELL RUMP PERMIT <br />At, 11STYD3'.3c —