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1 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZEITON AVENUE - STOCKTON CA 95205.6232 (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT <br />r-APIKI:, T YEAR FROM UATE ISSUED <br />JOB ADDRESS(�T o� t—Vfe!LArC��] <br />CYTY/ZIP f �/t/iI/l.�j�I ) <br />1 <br />CROSS STREET pr) Os+ aj <br />�T�7/ <br />APN 1 / —7"001 PARCEL SIZE IN rdSLAND USE APPLICATION # <br />G <br />OWNER NAME sz-"5 <br />0 PHONE <br />OWNER ADDRESS 0'-"" <br />CITYISTATE/ZIP <br />CONTRACTOR <br />PHONE <br />CONTRACTOR ADDRFSr <br />%/��� <br />14 CITY/STATE/ZIP <br />SUBCONTRACTOR/CONSOLfAN�--� <br />PHONF�N <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CITYISTATE/ZIP <br />LICENSE )e7 C-61 D-09 <br />Other NUMBER 17aXPIRATION DATE <br />BILLING PARTTY:OWNER <br />CONTRACTOR SUBCONTRACTORULTANT <br />/CONS <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well <br />Monitoring Well(s) # of wells <br />Out -Of -Service Well <br />Well Alteration/Modification Other <br />Soil Boring(s) #of borings Geotechnical <br />Out -Of -Service Well Renewal Cross -Connection Repair <br /># of borings <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth 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 Plastic Stainless Steel Other <br />Grout Seal Depth It Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix17 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant I Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level It <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 />/ DEPARTMENT SE ONLY <br />Application Accepted By ��g�� Date �y % Area 1 Employee ID#AS <br />Grout Inspection By �Date SPECIAL Well Permit <br />Pump Inspection By Date 1 WAIVER Received <br />Soil Boring In ection By Date-'"�" ���ff Co structed Well Depth ft <br />COMMENTS r%A aia a Ui h CQ�i in id Q , - <br />Codes I Info <br />EHD43-06 6/11/2019 <br />Invoice # I Well ID# <br />WELL(PUMP PERMIT <br />1�NT <br />FD <br />?021 <br />.qL TY <br />ME/V7- <br />