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w 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 /> C rr, ov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> S. �JOBADDRES (V ZL10 " C"/"p JtpL�/? 9/7o <br /> P1 lrI LAND USE APPLICATION#CROSS STREET � PARCEL SIZE <br /> mD <br /> A <br /> OWNER NAME C I y�/ �-f S-i��k�'�Y► PHONE w <br /> OWNER ADDRESS CITY/STATE/ZIP Jo,, )� <br /> CONTRACTOR '`I(,( l 1{/,,gyp l/!✓ � /[/ PHONE <br /> CONTRACTOR ADDRESS7001 <br /> ✓' / I W C /STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT G� �yL r/ PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS :J" `-'1 q�CS9 VA'1 �C rrY/STATE/ZIP r^'e <br /> `M1 <br /> LICENSE C-57 - C-61 I I D-09 Other NUMBER r17 EXPIRATION DATE C�0 <br /> BILLING PARTY: -OWNER 'CONTRACTOR J SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:-General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)_Arsenic(4393) <br /> INTENDED USE -Domestic/Private n Irrigation/Agricultural C Industrial n 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 Well Alteration/Modification i Other <br /> Monitoring Well(s) If of wells Soil Boring(s) #of borings JGeotechnical Lf of borings <br /> Out-Of-Service Well i Out-Of-Service Well Renewal i i Cross-Connection Repair <br /> New Pum -Pump Replacement i l Pump Repair G Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 4 Mud Rotary ❑Air Rotary J Auger Cable Tool Push Point n Other <br /> Proposed Well Depth I SO It Excavation in diameter C Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad Steel S Plastic -Stainless Steel -Other <br /> Grout Seal Depth 150 ft 4 Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> I Bentonite(20%solids) -Other <br /> Grout Placement Method�Pumped I Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By --Driller - Pump Contractor - Other <br /> Concrete Pedestal::Dimensions:Width ft Length It Thick in Christy Box _Stove Pipe <br /> PUMP Submersible G Turbine ❑Other HP Pump Set it Standing Water Level 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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FO�2,NSP TIONS-PLEASE <br /> ,CALL(209)9 3-7697 <br /> SIGNED TITLE J 9 /NY�'�' DATE It 0 Z <br /> C 0 9 ?a?1 <br /> ° Qui <br /> l °NMF°'jN7Y <br /> EPgR MFNT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date �C <br /> G /�`'L 7 �1 a Area I S�J Employee ID# //'' <br /> Grout Inspection By Date - SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date I Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount at Permit] Invoice# Well ID# <br /> Codes Info Ca h Remitted Service e # <br /> �a sa a <br /> EHD 43116 6/112019 / ��r�/,/ / WELL/PUMP PERMIT <br />