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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 />III t14-rcC�'UNU ►tsLt rtKMII <br />Sc Receive <br />Info <br />www.sjgov.org/ehd <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />l ^ <br />JOB ADDRESS 71''j �. l O <br />C- <br />1' 1 G (, c1 V-'Il�_ <br />CITY/ZIP _ <br />Li n 4Z h t <br />CROSS STREET !y E(t,,ko <br />fC,� <br />PN o 3, <br />y PARCEL SIZE 3�r�SS LAND USE APPLICATION # <br />OWNER NAME �/?h; YcrSSE <br />I �•�.' <br />I <br />III�,�., �. 3i?. <br />� <br />m� IL>�, r: / !`t <br />PHONE <br />OWNER ADDRESS U �j ��' <br />h Z <br />CITY/STATE2IP <br />CONTRACTOR �� C � � U <br />/'+ ✓` L v <br />a� 1 � t v ,,. " �.,-� <br />PHONE <br />CONTRACTOR ADDRESS 90a _ <br />f-,n�,,.;ti,,,�` <br />i✓�..,-,� <br />CITY/STATE2IP <br />I��-L• f C.� �11:��10 <br />SUBCONTRACTOR/CONSULTANT <br />56��^=� <br />�•J �:•.1r.X,'� <br />PHONE <br />SUBCONTRACTOR/CONSULTANTADDRESS `s. <br />w2, ��� C. ho -'ti <br />CITY/STATE/ZIP <br />S[•r�-- �� c..l7c.o-� <br />LICENSE )E C-57 C-61 <br />D-09 <br />' Other <br />NUMBER <br />EXPIRATION DATE 3G <br />BILLING PARTY: OWNER <br />Y CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) _ Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial CI Water Quality Monitoring >e Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />I YPE VF WORK New Well ❑ Replacement Well I Well Alteration/Modification Other <br />Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings X Geotechnical )# of borings <br />Out -Of -Service Well ❑ Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump u Pump Replacement ❑_Pump Repair Raise Well Casino <br />Drilling Method Mud Rotary C Air Rotary u Auger Cable Tool Push Point Other <br />Proposed Well Depth ko 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 1 Plastic Stainless Steel Other <br />Grout Seal Depth Ho ft *F, Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped ❑ Free Fall A Other /P1h 11 Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller a Pump Contractor Other <br />Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in Christy Box � Stove Pipe <br />PUMP Submersible Turbine n 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 />N <br />m <br />D <br />C=rART`i EN7 Misr v is LY Z� <br />Application Accepted By ' L— Date <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area -I Employee ID# <br />❑ SPECIAL Well Permit <br />F-1 WAIVER Received <br />Constructed Well Depth <br />S <br />ft <br />PE <br />Codes <br />Sc Receive <br />Info <br />Check#/ Amount Date <br />C s Remitted <br />Permit/ Invoice # Well ID# <br />Service Request # <br />3712 <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />