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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)4683420 <br /> NON-REFUNDABLE PEERMIIT •_, www.sigov.org/ehd /EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS / /�/262 ��Yrf D7�i CrTV21P /4!�/I� G� 9333 7 tmy7 <br /> CROSS STREET (/IV DJ/nJ� �1/� /�� APN Z Z Z 3)d D5 PARCEL SIZE C 3• LAND USE APPLICATION <br /> /#' �/ p <br /> OWNER NAME F/ ,4✓f�'J/� ,cle.4,AOzg CBCs PHONE OC"/ /A O� <br /> OWNER ADDRESS I ` CIO J`J �V�V CI/STATEVZP <br /> CONTRACTOR '' ,� �', I I I PHONE 'CSI e/Ire, <br /> CONTRACTOR ADDRESS v t 1 14410CI7YISTATEJZP 1\1�4-•' - -\ <br /> SUBCONTRACTOR/CONSULTANT 1 19l J PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATELZIP 1 <br /> 1� L <br /> as LICENSE C-57 C-61 r;D-09 1 Other NUMBER EXPIRATION DATE C2JD <br /> fa! BILLING PAR ;.i OWNER ]CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> t.- DOMESTIC WELL S PUNO:C General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)L Arsenic(4393) <br /> INTENDED USE ._ OmeStiCfP(IVate ❑InigatlOn/Agdcultural C Industrial rWater Quality Monitoring Soil Sampling/Characterization M � C <br /> p7 Public Water System ✓'�,m L <br /> Z L•I 0 different from Ovmer Water System Name Contact Name or Phone Numbercr <br /> _ L <br /> U 7 TYPE OF WORK eW Well Replacement Well Well ANeration/Modihcation i i Other D G <br /> 0 - '�Monitoring Well(s) Geotechnical#of wells - Sal Boring(s) #01°oririps n u of borings [— O <br /> —j i Out-Of-Service Well _ Out-Of-Service Well Renewal a Cross-Connection Repair -T <br /> _Z Q D New Pump 7 Pump Replacement ❑Pump Repair U Ralse Well Casing <br /> 0 Y ] WELLCONSTRUC71 (' z <br /> •1 —,i Dulling Method`JJJ}���/MMMud r'Air Rotary _Auger Cable Tool 7 Push Point = Other �'� <br /> Q Proposed Well Depthfl Exravatlon In diameter C Open Bottom C Gravel Pack/Gravel Size in diameter I i 1 <br /> 7 Conduc r Casing in diameter / Conductor Casing Depth ft ; z <br /> Well Casing Diameterin Thickness/Gauge/ASTM Sched L Steel XPlastic ,Stainless Steel 0 Other y <br /> .� If Grout Seal Depth ft C Neat Cement(94 Ib ba 10 galpw�ater) C Sand Cement sack mix/7 gal water <br /> 7 LLI -1 Bentonite(20%solids) Other - <br /> 6 Grout Placement Method Pumped Fr Fall Other Retardant/Accelerator(name) <br /> .a'4///•q' PEDESTAL Installed By Duller ump Contractor ❑ Other #74 <br /> 1 Concrete edestal CDI sions:Width R Length 11 Thick in L Christy Box 0 Stove Pipe <br /> 7 SubmersibleC Turbine C Other HP Pump Set ft 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 1:� DV NCE N CE REQUIRED FOR INSPEVI I NS,/-/PLEASE CALL(209).953 7697 t ` <br /> SIGNED TITLE `��"r DATE <br /> 0 <br /> pqY <br /> RETE ENT <br /> JU V FD <br /> AI 3® 2020 <br /> ENVD PARTMENT USE ONLY q ��PM�NQUIN �q Nr y <br /> fe -`.�1 Z 1" + �K MENr <br /> Application Accepted By_T• / Date 3 �7gyi O Area 1 r L Employee ID# <br /> I'G /� 'I <br /> / Grout Inspection By / r'r= _ Date X SPECIAL W.11 Permit <br /> �e Pump Inspection By J Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth H <br /> COMMENTS G'(l . 11 I R C 1') , Nit,is ,r A� -s . J I o,) foet ly <br /> fi> tslCC Et C'F'sft.�/P '1+C7pJ pt--writ, :rNc1of�"W,.tN E 56"s�FiA J%! (101A WPI S <br /> PE Sc Received Check#! Amount Date PerrtlW Invoice t Well ID# <br /> Codes Info Cas Remitted ServlcaR usstt <br /> r .7 U% Irk <br /> 3,11 / <br /> LI=eco 470 <br /> EH043.06 6111/2019 / WELL/PUMP PERMIT <br />