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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 /> n rn <br /> JOB ADDRESS /�r � �N� CITY/ZIP Ih m <br /> > D <br /> CROSS STREET �� r APPN PARCEL SIZEy./ LAND USE APPLLIICATION)#/ o <br /> OWNER NAME Ytt(C /C. —' PHONE MJ��l— 'L�b 6 N <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR I1t-A o*r,,, wlt , PHONE 13 L <br /> (7 <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP et'4;/ <br /> 'l <br /> 0, 'Ippe' � <br /> SUBCONTRACTOR/CONSULTANT �' PHONE 3:Zw: <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE -< 11 -1C-57 Cl C-61 D-09 Other NUMBIP <br /> ER ;'11 1 1 EXPIRATION DATE <br /> BILLING PARTY: '6WNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE -..e 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 or Phone Number <br /> TYPE OF WORK VNew Well eplacement Well ❑ Well Alteration/Modification ❑ Other P:n11 <br /> 11 Monitoring Well(s) #of wells ❑ Soil Borings) #of borings ❑ Geotechnical aft I <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair JAN <br /> ew Pum Li Pump Replacement 11 Pump Repair L1 Raise Well CasingJAN <br /> WELL CONSTRUCTION <br /> Drilling Method .@'Mud Rotary Li Air Rotary El Auger 11 Cable Tool El Push Point ❑ Other �JOgQVtN CO <br /> Proposed Well Depth '9'OV ft Excavation t` in diameter El Open Bottom 11 Gravel Pack/Gravel Slze TM OEPAa �eter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter F in Thickness/Gauge/ASTM Sched 2-01D ❑ Steel Plastic ❑ Stainle/s�st Steel ❑ Other <br /> Grout Seal DeptlT7_01Z� ft ❑ Neat Cement(94 Ib bag/5-10 gal water) 11�,_`Sand Cement /V sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By kt'briller ❑ Pump Contractor G Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP >IeSubmersibleo 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 /> MIN M 48 HH UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE {U/QJL DATE <br /> r <br /> L <br /> 4- v <br /> 0 <br /> L <br /> QEPIARTMENT US ONLY <br /> Application Accepted By 9AVt}.J Date L` / Zee- I Area Employee ID# <br /> Grout Inspection By Date ��S1�f'2A/',2� ElS ECTAL Well Permit <br /> Pump Inspection By /� � ''' Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date ConstructeWell Depth y ft <br /> COMMENTS ))( P.��T � t i✓� S (� V-U l P <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info 13yi C—asF, Remitted Service Request# <br /> k 439 9v 420O.2 <br /> I a) 0 1 W(Q <br /> I � <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />