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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 />www.sjgov.org1ehd <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS iwL(u' Ll <br />l�— <br />CRY/ZIP <br />CROSS STREET i` I �'�'c' <br />t L <br />APN �.' `t `L <br />�- PARCEL SIZE _7°i C <br />LAND USE APPLICATION # <br />OWNER NAME !�A;8t/ cA=�AI <br />(%J1 <br />PHONE <br />/`f'KO <br />OWNER ADDRESS Q MC `' <br />I ki <br />CITY/STATEIZIP <br />CONTRACTOR N< U <br />� <br />PHONE <br />c <br />CONTRACTOR ADDRESS c(L) Z <br />i <br />1' �uS, v � i <br />\ Wt.- <br />CITY/STATE/ZIP <br />V CA U <br />SUBCONTRACTOR/CONSULTANT <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CITYISTATE/ZIP <br />LICENSE k C-57 C-61 <br />D-09 <br />Other <br />NUMBER L L "1 `' ` ( <br />EXPIRATION DATE `5� ?-01 1 <br />BILLING PARTY: OWNER _ <br />CONTRACTOR <br />SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) A Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED 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 ❑ Well Alteration/Modification Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of b°nngs -Geotechnical Z # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal Cross -Connection Repair <br />❑ New Pump o Pump Replacement ❑ Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary r Air Rotary -JC Auger ❑ Cable Tool Push Point Other <br />Proposed Well Depth I � ft Excavation (, in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />i i Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness Gauge/ASTM Sched Steel Plastic i i Stainless Steel 1 Other <br />Grout Seal Depth ft eat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) )(Other <br />Grout Placement Method Pumped a Free Fall Other - Retardant / 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 -1 Submersibles Turbine -: Other HP Pump Set ft Standing Water Level ft <br />1 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 />dE.PIRTMENT USE ONLY <br />Application Accepted Bylow Mew ate Z C q/ 1,9 � <br />_ Employee ID# E � <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE Sc Received ec Amount Permit/Codes Info B ash emitted ate Service Request # Invoice # Well ID# <br />EHD43-06 6/11/2019 WELL /PUMP PERMIT <br />