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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.SI oy.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> TY/L <br /> JOB ADDRESS �J C CIP C L <br /> T 1 /�, D <br /> CROSS STREET a APN OH a l-0SO -L)�PARCEL SIZE BLAND USE APPLICATION#Q/ rY�yn( yp <br /> OWNER NAME �7 G� 1 ` PHONE O -z {tQ-SBI r/? <br /> OWNERADDRESSI 1 �y�'�'�a 1�a, CrrYlSTATE/ZIP ` <br /> es <br /> CONTRACTOR `1� PHONE ['`,== 45 `� Ip(�`Z e <br /> CONTRACTOR ADDRESS 19 CI Y/STATE/ZIPM O de-S- o,C A q 5 3 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CrrY/STATE/ZIP <br /> ` <br /> LICENSE XC-57 I C-61 D-09 Other NUMBER 29 P 13 E%PIRATION DATE <br /> BILLING PARTY: OWNER ONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigadon/Agricultural Industrial i Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK XNewWell Replacement Well D Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells D Soil Boring(s) n of borings Geotechnical a of borings <br /> Out-Of-Service Well D Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement E Pump Repair Raise Well Casing <br /> WELL CONSTUCTION <br /> Drilling Method Mud Rota Air Rotary Auger E Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation Aq--in diameter r- Open Bottom Y_Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter�in Thickness/Gauge/ASTM Sched�.I( Steel Plastic Stainless Steel Other <br /> Grout Seal`D�theft Neat Cement(94 Ib bag/5-10 gal water) ix/7 Sand Cement sack n gal water <br /> 7 Gentonite(20%solids) Other <br /> Grout Placement Method umped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Drillerump Contractor Other <br /> E Concrete Pedestal DI ensions:Width ft Length ft Thick in - Christy Box 1 Stove Pipe <br /> PUMP F'Submersible Turbine Other HP Pump Set It 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 /> INIMUM 48 HOUR ADVANCE NOTICE REQUIRED OR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED <br /> • TIT DATE <br /> ^FNT <br /> 'V`D <br /> 0 2021 <br /> S N J I f IN COUNTY <br /> EN\jIRMIMENTAL <br /> PARTMENT <br /> ER RTMENT LVSE ONLY <br /> Application Accepted By / DaW Area Employee ID# <br /> Grout Inspection By I _ 4' Date '- SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Re eiv d Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Code Ifo A v C Remitted c Re uest# <br /> EHD 43-06 6/11.2019 WELL/PUMP PERMIT <br />