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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 />NUN-KEFUNDjLj=9RMIT <br />JOB ADDRESS f 0 <br />CROSS STREET I T o r <br />OWNER NAME 16 ( (4(40 <br />OWNERADDRC:a' <br />AP//N�� �L C� d •O J'7 PARCEL SIZE r' <br />r I AA _ <br />CONTRACTOR ADDRESS ✓' I F,I K t I V I« CITY/STATE%ZIP <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTORICONSU ANT ADDRESS IV �rt�STATE21P <br />LICENSE C-57 C-61 D-09 Other NUMBER �L//JJ_L/V�J <br />BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTORICONSULTANT <br />cc <br />_- <br />V <br />Q <br />DOMESTIC WNLAMPUNG: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USEA 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 a Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) of borings ng(s) Geotechnical # of borings <br />Out-Of-Servi Well Out -Of -Service Well Renewal Cross -Connection Re air <br />P <br />_ New Pump pump Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION � <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth It Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth It Neat 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 Free Fall Other Retardant / Accelerator (name) <br />C\ <br />�J <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Leng ft Thi in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set v ft Standing Water Level It <br />(-1 <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN (�1 <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 />MINIMUM48 DVAN NOTICE�QHI D FO S/1PEC,tTIO/NS/�-�PLEASE CALL (2(��(97��p��5/�J 7�/Tp7 <br />SIGNED V(_/t TITLE _V 1 i 1 � 0 I V 1 r, 1/ \ DATE V/ C., J� I <br />RFq yMF <br />Ps/v T <br />SEp 3,20 <br />O <br />DEPARTMENT USE ONLY �N�q�' ?, <br />h %o V <br />Application Accepted By �4— Date 3 3 Area S C Employee ID# ry0 pq FH Co <br />- �Nrr <br />Grout Inspection By Date SPECIAL Well Permit h'T414 <br />Pump Inspection ey A94� Date 1'\d*�5 7 OZ` WAIVER Received r <br />w. <br />Soil Boring Inspection ByDate Constructed Well Depth ft <br />COMMENTS <br />EHD4 06 6/11/2019 <br />WELL /PUMP PERMIT <br />