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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 />NON-REFUNDABLE PERMIT <br />mvw.Sjgov.Orglehd EXPIRES 1 YEAR FROM(�DATE ISSUED <br />, l (1 <br />JoB ADDRESS 3g N W G <br />/���_ p <br />y'C„I 1 rote CITY/ZIP _'3txr- (� / (As 1 C/ q <br />CROSSSTREET <br />-O �(l <br />SIZA ('LAND USE APPLICATION# <br />C,}.���� j,,'DC- I,,/Y <br />OWNER NAME 'StfborAC`XT <br />{(`-�AAPN (�'/�1t`r�'�```O' {D <br />/w�y1-PARCEL <br />cid Nom' IJI6�IVr q—,4-7—PHONE-(.10"l)61;3-f`-7000 <br />,l JrA�1V111t\�V� <br />OWNER ADDRESS _ :10 1 N I- tM.4I <br />�(� S� CITY/STATE/ZIP S I O ck I V rl l ((A qS 30 L-. <br />CONTRACTOR V a' "' w (11 lYj, <br />/� <br />ql (jQ ) q(0q - 17 `)C/ <br />CONTRACTOR AODREss ' � <br />Ga <br />CITY/STATE/ZIP V Q 14 <br />' `1 ` <br />SUBCONTRACTOR/CONSULTANT W W <br />G(19 �I � � ) <br />(�{ ( r, I n / <br />1 I 4 W <br />V{ R, �i�i/)JyQ <br />c-'\G..U.r <br />� � �r ja,,&O( <br />'''PHHO,NE [(4W)612- <br />/)1y6�,I�`2- <br />SUBCONTRACTOR/CONSULTANT ADDRESS 3 Sy Yj(A}NVI rl(/�.I VIVj• CITY/STATEIZIP �N4 OaGV(A -[/ f1 , (P S6 rI <br />SUBCONTRACTOR/CONSULTANT <br />LICENSE ./C-57 C-61 D-09 <br />Other NUNBER -7Q2 u oy EXPIRATION DATE qbk) (202,Z– <br />202,2 <br />BILLING PAR TV: DOWNER <br />BILLING <br />__CONTRACTOR ✓SUBCONTRACTOR/CONSULTANT <br />DOMESTIC: WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) : Arsenic (4393) <br />INTENDED USE L: DOmeStIC/PFiVate V IrrigationlAgricullural - Industrial Water Quality Monitoring _. Soil Sampling/Characterization <br />El Public Water System <br />It different from Cwo, Wale' System Name Contact Name or Phone Number <br />TYPE OF WORK 0 New Well Replacement Well Well Alleration/M-1-1inn - Other <br />G Monitoring V fells) # of wells Soil Borings) _ _ of boring's /Geotechnical of bonn�s <br />t l Out -Of -Service Well : Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method <br />Proposed Well <br />Well Casing <br />Grout Seal <br />Mud Rotary Air Rotary N Auger Cable Tool Push Point Other <br />DepthI"; n Excavation 6 _ S in diameter .. Open Bottom !] Gravel Pack/Gravel Size in dia <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Diameter _ in Thickness/Gauge/ASTM Sched - Steel Plastic , - Stainless Steel Other <br />Depth is ft ✓Neat Cement (94 Ib bag/5-10 gal nater) Sand Cement sack miri/7 gal <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped )Free Fall VOther }f1M 1 k 9 e a and / Accelerator (name) <br />PEDESTAL Installed By : Dnller Pump Contractor Other <br />Concrete Pedestal ..,Dimensions: Width It Length R Thick in Christy Box Stove Pipe <br />PUMP,. Submersibles: Turbine Other HP Pump Set ft Standing Water Level ft <br />---------- <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 />MINIMUM 1�1�8 0 ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />, - PLEASE CALL (209) 953-7697 <br />SIGNED WtZ `f'�/ TITLE StR}�,Enj I IjenDATE <br />% DEPARTMENT U E N L Y <br />Application Accepted By `— Date ' �3 <br />Grout Inspection By k,} i.K.- Date Z <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Date <br />Area I Employee ID#_m.� <br />SPEC AL Well Permit <br />WAIVER Received <br />Constructed Well Depth f' <br />EENT <br />VED <br />13 2021 <br />AN <br />VM;rA,CO'UNi' <br />END4}06 6/11/1019 WV ,I, li�W L I'I't-.':n <br />rmIrrinFg9 P-1•A.,rI"WXMMi <br />101+IrEY:0?: <br />END4}06 6/11/1019 WV ,I, li�W L I'I't-.':n <br />