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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.sjgov.org/ehd > EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ` lI`A �/" _ CITY/ZIP <br /> a D <br /> CROSS STREET b —APN OI 119 0d 1 _PARCEL SIZE LAND USE APPLICATION# A <br /> OWNER NAME/ S /� _ � _ PHONE N <br /> OWNER ADDRESS CITYISTATE/ZIP �/ -2 <br /> CONTRACTOR sDav {Sy i ///rr _ l PHONE23 Y- 'e'e/7 <br /> -2—r <br /> ADDRESS_/'" � ^�L /Z? CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT ! i/ n� /'��r�YJ� PHONE �/7 3120 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE -K-57 1_1 C-61 LI D-09 U Other NUMBERa"_L7?a,3 EXPIRATION DATE 6- <br /> BILLING PARTY: OWNER I CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:x General Mineral/Coliform Bacteria(4391A Dibromochloropropane(4392), I Arsenic(4393) <br /> INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK Xew Well Replacement Well H Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> Xlew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point El Other <br /> Proposed Well Depth ft Excavation -L in diameter ❑ Open Bottom % Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter e- <br /> in Thickness/Gauge/ASTM SchedW ❑ Steel f lastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth1��ft ❑ Neat Cement(94 lb bag/5-10 gal water) 'lcSand Cement ,r sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method 0Purnped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other on <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> [Pump ubmersible❑ Turbine ❑ 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 COMPENSATION LAWS. <br /> MINIMU 4 HVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNEDTITLE orDATE r0 <br /> VVII <br /> Q1 <br /> titR M <br /> DEPARTMENT US j1:6-NLY � <br /> Application Accepted ByG�- � I�� n _- Date s 8.�7 _ Area Employee ID# <br /> Grout Inspection By 4AU,`)!J (�2 'Z- Date W�il_ofw SPECIAL Well Permit <br /> Pump Inspection By� S(nCQ 'd a Date g140 1202( WAIVER Received <br /> Soil Boring InspectionBy _ Date Constructed Well Depth <br /> COMMENTS E.X� Y4e) fo remAlYl. Amusi 6e A o% wkyr-iN' um -9-0&e+ G� <br /> PE Sc Received hec Amount Permit/ <br /> Codes Irrfo B Cash Remitted Date Service Request# Invoice# Well ID# <br /> 9379 10 / ab '91 - <br /> L1361 I _ 50 <br /> L)3q _ O <br /> �3�0 OSa <br /> r_I-ID 43-06 6/11/2019 WELL/PUMP PERMIT <br />