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WELL/PUMP PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -6232 (2091466-347r <br />JOBADDREsa-,T Harnev Ln <br />ww.sjgov.org/ehd EXPIRES 1 YEAR FF <br />clry/zIP Lodi, CA 95240 <br />0 7 0 6 8 PARCEL SIzE7 9. 3 6 LAND USE APPLICATION # <br />ISSUED <br />m <br />SUBCONTRACTORICONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE X C-57 C-61 D-09 <br />BILLING PARTY: _ OWNER <br />Other__ <br />'.CONTRACTOR <br />DOMESTIC WELL SAMPLING: I _ General Mineral/Coliform BaCterla (4391) : DibrOmochlorODronnnA 143Q91 I- Arconir !41041 <br />T r.rrvnn rvew Welt i Keplacement Well D Well Alteration/Modification G Other <br />- Monitoring Well(s) #of wells D Soil Boring(s) _ Cotbonngs i Geotechnical of bodogs <br />Out -Of -Service Well D Out -Of -Service Well Renewal C Cross -Connection Repair <br />- New Pump ump Replacement C Pump Repair C Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method _. Mud Rotary Air Rotary = Auger ❑ Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom I Gravel Pack/Gravel Size in diameter <br />j Conductor Casing in diameter ! Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad Steel = Plastic ---Stainless Steel � Other <br />Grout Seal Depth ft 7 Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mixl7 gal water <br />Bentonite (20% solids) ; Other <br />Grout Placement Method -- Pumped . Free Fall C Other _ Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller _ Pump Contractor L Other <br />- Concrete Pedestal Dimensions: Width ft Length It Thick n Christy Box Stove Pipe <br />PUMP Submersible _ Turbine -Other HP Pump Set _ h 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 COMPENSATI LAWS. (� 'I- 2 <br />SIGNED TITLE ` C ;L �rat-{V ( DATE l )// q /2. <br />ll <br />?E YMFNT <br />CFS QED <br />UG <br />)4 <br />F� QU/Al <br />DE gR� � Y <br />NT <br />DEPARTMENT USE ONLY �Jl <br />Application Accepted By �6�- <—" Date _ } 1 Area l �� ( Employee ID# <br />Grout Inspection By Date i SPECIAL Well Permit <br />Pump Inspection By Date 7 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE SC Recelved Check#! <br />Codes Info ash <br />r <br />Amount Permit/ <br />Date <br />Remitted i RectuestAl, Invoice # Well ID# <br />11 71 1 V44 <br />END-. tll11/2019 //y/� <br />'NEIL /PUMP PERMIT <br />'. y- 80 3,F-6 5Y8 <br />