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fi <br />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 �/ G <br />E.yR77MITMeru. <br />ov.or lend D <br />tAPIKhb I YEAR FROM ATE ISSUED <br />JOB ADDRESS +6-M /Y Q Q� /[Tru' /"ndael CRY21P 56eei i !mins- <br />CROSS STREET wpr/IYI�I S /tB� AP QaZ PARCEL SIZE &f&kA.LAND USE APPLICATION # <br />OWNER NAME <br />OWNER ADDRESS <br />CITY/STATE/ZIP <br />PHONE <br />CONTRACTOR Me II D Al VSon C4 SSOc• PHONE 2,9f 7G7-326`1 <br />CONTRACTOR ADDRESS !70'L ,�h �ltd�r%K VV�ti CITY/STATE/ZIP �ddj' e*4 ?5-,.rf� <br />SUBCONTRACTOR/CONSULTANT Q11t ( PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE � C-57 C-61 ID -09 Other <br />BILLING PARTY: - OWNER ACONTRACTOR <br />CITY/STATE/ZIP <br />NUMBER 66174V/ EXPIRATION DATE <br />�►SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: _ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) - Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial 1 Water Quality Monitoring )pSoil 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 ! _i Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells p Soil Boring(s) _ p of borings ,Geotechnical # of borings <br />71 Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />New rump rump replacement a rump mepair raise vveu uasing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary a Auger Cable Tool ❑ Push Point Other <br />Proposed Well Depth / 5 - 20 ft Excavation _6 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 i Stainless Steel i Other <br />Grout Seal Depth ft Jif Neat Cement (94 Ib bag/5-10 gal water) J Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped ❑ 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 ❑ Submersiblei.'. 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 />MVO UM 48 HOpf ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />ARTMENT S� ONLY <br />Application Accepted By Date Area ` G Employee ID# ��L� <br />Grout Inspection By `- ' f Date SPECIAL Well Permit <br />Pump Inspection By Date L; WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS V;.'r .J-ruLttP<t to SuTi'uCJz Ca'f,xClL due 'r0 , ;iL rL: ..} fn 1pi1��1�' <br />PE Sc Received Check#/ <br />Codes In BY <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />It <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />