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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 www.s' ov.or lehd EXPIRES 1 YEAR FROM DATE ISSUED N <br /> flfl A if Awe p d GR �9C22.p M <br /> ,iy A;4,4NT I�� CmrIZIP m <br /> J08ADDRE:.�7 S <br /> � O <br /> T q10 U44 APN QD7-✓/1*'18 PARCEL S1ZE v�4GtLAND USE APPLICATION m <br /> CROSS STREE <br /> OWNER NAME /lrY/N PHON07J21 C,JIm <br /> /J <br /> e !' l/J.•S,I/�Tt/��i��vJTc �4J' CITY/STATE/ZIP &PHONh <br /> �.y&g <br /> Jt34-71_/Oi',aD6 <br /> XO <br /> OWNER ADDRESS /P S-77 <br /> fA37­ <br /> CONTRACTOR <br /> te`+rte y//� ���/"'aYYY J ���O <br /> CONTRACTOR ADDRESS 17y V 7 l Il���� 7' CITYISTATEJZIP 6.p N 0 _ <br /> PHONE <br /> SUBCONTRACTORICON5ULTANT <br /> SU13CONTRACTORICONSULTANT ADDRESS 'CITrIY/STATErZJP <br /> 7� <br /> LICENSE XC-57 n C-61 r' D-09 n Other NUMBER J'79 9 EXPIRATION DATE <br /> BILLING PARTY: U OWNER U CONTRACTOR L SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)C Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Pdvate ❑Irrigation/Agricultural 17 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System Contact Name or Phone Number <br /> If different from Owner. Water System Name <br /> TYPE OF WORK New Well 7 Replacement Well O Well Alteration/Modification O Other <br /> ❑Monitoring Wells) #of wells ❑Soil Boring(s) <br /> #of borings ❑Geotechnical #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement_ :1 Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method KMud Rotary C Air Rotary 7 Auger 0 Cable Tool C Push Point C Other <br /> Proposed Well Depth !VDO ft Excavation /Q in diameter 7 Open Bottom KGravel Pack/Gravel Size in diameter <br /> 1 1 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter-in Thickness/Gauge/ASTM Sched 7 Steel ''Plastic 0 Stainless Steel D Other <br /> Grout Seal Depth 100 ft n Neat Certrynt(94 Ib bagl5-10 gal water) -1SendCement sack mix/7 gal water <br /> ❑Bentonite(20, solids) C Other AJFA1TaN/7-t <br /> Grout Placement Method umped C Free Fall 0 Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller C Pump Contractor ,Y-,Other <br /> U Concrete Pedestal uDimensions Width ft Length ft Thick n L Christy Box L Stove Pipe <br /> PUMP I I Submersible 1 Turbine 1 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPE SATION LAWS. <br /> MINI 48 HOUR DVANCE NOTICE REQUIRED FOR INS CTIONS-PLEASE CALL(209)993-7697 <br /> SIGNED TRLE 41.00W7DATE 3 <br /> IT <br /> ✓p� L-I— <br /> / IA/Ct <br /> III <br /> Ty �N7'Y <br /> D P RTMENTUS,EE O Employee ID# <br /> LY <br /> Area <br /> Application Accepted By Date 'J Ll �� <br /> zC� <br /> Grout Inspection By AW Z Date,� -?� - ❑ SPECIALWell Permit <br /> Pump Inspection By' Date ❑ WAIVER Received O <br /> Sail Boring Insp =n By Date (�C-onstruc ed Well Depth ft <br /> COMMENTS ✓D(ti S a� C� / QAC Ca(iP�'Oh Ai/��r �7 ��I�ZiJZ� <br /> PE SC Received hec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Remitted Service Re uest# <br /> -) 11a :, 3 2 �u P uP <br /> L)3 c i a `1 13 1�1 V)P00411#0 <br /> s6F i�J � 30 23 LU W <br /> EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />