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WEL PUMP ERMIT <br />SAN JOAOUIN COUNTY E PARONMENTAL HEALTH DEPARTMENT 1868 EAST HAZE LTOt4 AVENUE • STOCKTON CA 95205 -6232 (209) 468.3420 <br />NON-REFUNDABLE RERMIT 7 www.sjgov.org/ehd EXPIRES 1YEAR FROM DATE ISSUED <br />JOB ADDRESS _.7 ff 1 .�a.CITrIZIP :-fi i �1%:✓,�� <br />CROSS STREET C%' f �LftJ.''• r"•Li ! APN 4'�% L "�Jf L"'Z i9 PARCEL SIZE' LAND USE APPLICATION It <br />OWNER NAME t� i .53Yt �•.Z i S PHONE '�f /( 3tJ."E7� <br />/ 1 <br />OWNER ADDRESS fa: _.3`1 J °.� wT • L CnY/STATE/7JP J e2e "A%set Al. i-.-.+� ! 5'29- ° <br />CONTRACTOR A ov e 04- �`� � .:.C. ir% 4- PHONE f cG'' % 7 573 2� —L6 <br />CONTRACTOR ADDRESS / Ca e. 4,i 6-t- CITY/STATE/LP •J a iyez- . e,:4 <br />SUBCONTRACTOR/CONSU -TANT PHONE <br />SUBCONTRACTOR/CONSU TANT ADDRESS CITY/STATEZZ/P r� y y,r-y <br />LICENSE 1� C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 2- �7 /" EXPIRATION DATE ✓ J® I <br />BILLING PARTY: ❑ OWNER ❑ CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMP NG: ❑ General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE Xbo estidPrivate 0 Infgation/Agricultural ❑ industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />0 Pubic Water System <br />If 6 rent from Owner. Water System Name Contact Name or Phone Numher <br />TYPE OF WORK r_ Nem Well 0 Replacement Well 0 Well Alteration/Modification ❑ Other <br />❑ Mor toring Wells) # of wells D Soil Boring(s) # of borings 0 Geotechnical If of borings <br />C OutOf-Service Well 0 Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />Ne Pump 0 Pump Replacement 0 Pump Repair ❑ Raise Well Casing <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary D Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth It Excavation in diameter D Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Con Juctor Casing in diameter / Conductor Casing Depth it <br />Well Casing Diame er _ in Thickness/Gauge/ASTM Sched ❑ Steel 0 Plastic ❑ Stainless Steel D Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5.10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Ben onite (20% solids) D Other <br />Grout Placement Meth d D Pumped ❑ Free Fall D Other ❑ Retardant /Accelerator (name) <br />PEDESTAL Install d By ❑ Driller Pump Contractor 0 Other <br />0 Cc rete Pedestal ❑Dimensions: Width ft Length ft Thick In 0 Christy Box 0 Stove Pipe <br />PUMP Sub <br />aid <br />Turbine ❑ Other HP— IT Pump Set�p_ft Standing Water Level ft <br />I HEREBY CERTIFY AT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY 0 DINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND AC WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENS TION LAWS. <br />MINIMUM HQ4)R ADVANCE NOTICE REQUIRED FOR IN PEC ONS - PLEASE CALL (209) ,9 33--7697, <br />SIGNED /U/� .%:" .� r /t TITLE I _ DATE ,-7!�ZG'• <br />y <br />H <br />D <br />v <br />m <br />H <br />PA <br />14A <br />yM <br />Mq y 12 FO <br />2020 <br />TNDEpq�T 4 <br />% DEPARTMENT US ONLY <br />Application Accept By ��lF' `,/ / Date S <br />q ! <br />Area / Employee ID# J <br />Grout Inspecdc n Byq <br />Date <br />❑ SPECIAL Well Permit <br />'_ <br />Pumpinspecti By AS(o ��OLA'S ` l <br />Date <br />❑ WAIVER Received <br />Soil Boring Inspectic n By <br />Date <br />Constructed Well Depth ft <br />COMMENTS <br />PE SC <br />Codes Info <br />ceived Check#/ Amount <br />81G Gash Remitted <br />Permit/ <br />Date Service Re uest # Invoice # Well ID# <br />EHD43.06 6/112019 I J67 8-2,30�O <br />WELL /PUMP PERMIT <br />