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01 <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZE LTON AVENUE-STOCKTON CA 95205-6232(209)46&3420 <br /> NON-REFUNDABLE PERMIT WWW'SMOV.orglohd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Li /C \ I `�. C(,�(.'• I I y \ 21P �C7�C( I VL� ��`, �-C m <br /> 4j f� D <br /> CROSS STREET AIA APN (� 7i r/D�J�I1 PARCEL SIZE�/ LAND USE APPLICATION# {` p <br /> OWNER NAME 1�1 1 � — 1�'1 I�6y(, +'• �(' I [..1 'I V 1 jPHONE -)CC( <br /> OWNERADDRESS�I 1111 I Ct r �1 [� Dy CITYISTATEIZIP 1 - L- <br /> CONTRACTOR C�t 1 ��C L"\..''f I ( /V I I I 1 ('I L PHONE G7 / L <br /> ` <br /> CONTRACTOR ADDRESS I�L-'K II"'IUz� CRYISTATERIP �21LJL-C <br /> SUBCONTRACTOR/CONSULTANT 1 A 1 PHONE <br /> SUBCONTRACTOWCONSULTANT ADDRESS CITtYISST`A`TEMP ] <br /> LICENSE C-57 i t C-61 �I D-09 Other NUMBER v t`r '�PIRATION DATE <br /> BILLING PARTY: 'I OWNER '_CONTRACTOR '..i SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:.'General Mineral/Coliform Bacteria(4391))(Dibromochloropropane(4392)Lj Arsenic(4393) <br /> INTENDED USE mesOUPnvate ImgaborgAgnculturai ;1 Industrial Water Quality Monitonng a Soil SamplinglCharactenzatiGn <br /> Public Water System <br /> If Orr—t from Owner Wale,System Name CoMacf Name w Phom Number <br /> TYPE OF WORK New Well Replacement Well r,Well AlteratioNModificatlon Other <br /> :Monitoring Well(s) #ofwells Sol Bonng(s) Yof bo—V Geotechnical •ofbonnoc <br /> Out-OfSarvice Well n Out-Of-Service Well Renewal II Crosf;Connection Repair <br /> New Pum Pump Replacement 1 Pump Repair 1 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method'�r/Mud Rotary u Air Rotary a Auger i,Cable Tool 11 Push Point I Other <br /> Proposetl Weil Depth i3u 0 E Excavation A!:f_in diameter .1 Open Bottom ravel Pack/Grevel Size in diameter <br /> 1 Conau Casing in diameter I Cond ctor Ca Ing Depth n <br /> Well Casing Diameter in Thidkness/Gauge/ASTM Sch:d �� n Steel/kPlasbc n Stainless Steel ;':Other <br /> Grout Seal Depth It n Neat Cement(94 1b ba9/5-10 gat water) 'Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) I Other <br /> Grout Placeme(�t Metho Pumped C Free Fall !.I Other !!Retardant/Accelerator name) <br /> PEDESTAL Installed By 1 Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions'.Width ft Length h Thiele in Christy Box !Stove Pipe <br /> PUMP ':Submersible,1 Turbine Other HP Pump Set ft Standing Water Level h <br /> I HEREBY CERTIFY THAT 1 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 �j��q��AD NCE NOTICE REQUIRED FO INSPtCIT NS-/PLEASE CALL(209)j951-7697 <br /> 'RHIlO 1 TITLE � <br /> y 1 �'Y DATE <br /> RF yMFN r <br /> CF V ED <br /> -- --- -( _ _ SEP <br /> ?4 2020 <br /> y FPMEN k 7-Y <br /> �RTMENT <br /> nEPARTMENT ILQr' <br /> Application Accepted B�' Da' ��/N�rv Area I Employee ID# D <br /> Grout Inspection By Date i SPECIAL Well Permit <br /> Pump Inspection By Date 1WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth rt <br /> COMMENTS <br /> PE SC Recelved Check## Amount Date Permit/ Invoke Well IDM <br /> Codes Into Cash Remitted Service Request# <br /> �I fyao I' <br /> y3�r �Itf 190 i# bJA 16W <br /> i 75 <br /> Pay�r <br /> , r.)^t EHO s]-00 an 12019 WELL/PUMP PERMIT <br />