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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(208)468.9420 <br /> NON-REFUNDABLE PERMIT wwW.sjqov.orq1ehd EXPIRES <br /> ��1 YEA"F OM DATE ISSUED <br /> LA <br /> (/ll/t. <br /> JOB ADDRESS o �. '] CITYC2IP RI <br /> CROSS STREE AP <br /> 9-D/ + RCEL SIZE✓ ��LAND USE APPLICATION# <br /> PHONE�I WA e1 -3D 1 0 <br /> OWNER NAME I J U i 'V 1 m <br /> OWNER ADDRESS !SCA VnCITY/STATE2IP <br /> CONTRACTOR bit I� G-, PHONE <br /> CONTRACTOR ADDRESS CH—(L) CITY/STATEIZIP P�:=`'VW U W 0�1 J K- <br /> L% <br /> SUBCONTRACTOR/CONSULTANT ' " w PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 11C-61 ❑D-09 11 Other NUMBER' `� 1 EXPIRATION DATE 1 <br /> BILLING PARTY: ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPUNG:.RrGeneral Mineral/Coliform Bacteria(4391)2ttibromochloropropane(4392)o Arsenic(4393) <br /> INTENDED USE Domestic/Private 0 Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> 0 Public Water System <br /> If ddferent from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well ❑Replacement Well ❑Well AHeration/Modification 0 Other <br /> ❑Monitoring Well(s) #of wells 0 Soil Boring(s) Oofborings ❑Geotechnical #ofbonngs <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement 0 Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rotary ❑Air Rotary D Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth:;;0C_) It Excavation��in diameter ❑Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> 0 Conduc r Casing in diameter / Conducto Casing Depth ft <br /> Well Casing Dlamet r Thickness/Gauge/ASTM Schedl�-� ❑Steel ^Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth 00ft ❑Neat Cement(94 1b bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br /> XBentonite(20%solids) ❑Other <br /> Grout Placement Method XPumped ❑Free Fall ❑Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller XPump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dlmenslons:Width ft Length ft Thick in 7 Christy Box ❑Stove Pipe <br /> ❑Submersible Turbine ❑Other HP Pump Set ft Standing Water Level tt <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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPEqSAj1ON LAWS. <br /> MINI UM AD CE NOTICE REQUIRED FO INSP�TIOON�SI-PLEASE CALL(209 76 7 <br /> SIGNED TITLE 1 r✓1 DATE <br /> NT <br /> D <br /> 20 <br /> E NN <br /> / JDEPARTMENT USE ONLY 7� /�{I <br /> Application Accepted By L4� Date �a �� �(n^Area 45 Employee ID# D A <br /> Grout Inspection By Date I Z� I(�7U C.�J ❑ SPECIAL Well Pe.it <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Igspection By Date Constructed Well Depth ft <br /> COMMENTS rCjY,r '} )Yi( [ / y1 •moi C tj} Qn r G, h�Y <br /> ltvbr CatoPl, <br /> PE SC Received XG146044 Amount a e Permit/ Invoice# Well IDS <br /> Codes Info B Cash Remltted Service R u st <br /> O r <br /> 0 ii 11 <br /> 3 70 II l <br /> EHD4306 6/11/2019 It/IJ LLID LIPCe.-jf _ J c1}'IJ'1 '0(' vie all qilli rSjeje & 4UJPUMPPERMIT � / <br /> rw��uS of nl ntr Coh}�t ►1�inu�e0► welly to Me norf'hf�S}. l' j CO - GR IV/abv'(? <br /> cj IIx4eof �I J <br />