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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 /> 7 /�ry i Vr <br /> JOB ADDRESS ��' Or=dNQF CITY/ZIP X011,3,00 <br /> 11,3'0 0 m <br /> /�16 y I �rAPN 13aavgS {j a <br /> CROSS STREET / ,r,,•_ PARCEL SIZE LAND USE AyPPLICATION#// O <br /> OWNER NAME /�[C.;( `fi b-Y•�•lG/C. ` �'V�r PHONE�DILCI <br /> ! to <br /> OWNER ADDRESS It°�t,L�c c �y CIN/STATE21P LJ '7 <br /> CONTRACTOR 10-A G•17�7.7s+•^�-^ ✓� 1 r PHONEE''�L3q, ` "'li'� <br /> CONTRACTOR ADDRESS +��� CITY/STATE/ZIP ec/wl PeR4-r <br /> r <br /> SUBCONTRACTOR/CONSULTANT�4 igao"2 1�' � PHONE 3 C•/-�� � <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE 'CCC-57 ❑C-61 ❑D-09 11 Other NUMBER 7� `'l g2 EXPIRATION DATE <br /> BILLING PARTY: ❑ wNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT t J <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE ,e Domestic/Pdvate ❑ Irrigation/Agricultural 0 Industrial ❑Water Quality Monitoring 0 Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK W'New Well eplacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Wells) #of wells ❑Soil Borings) #of borings ❑Geotechnical E® <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair sAW' C <br /> ew Pum ❑Pum Replacement ❑Pum Repair ❑Raise Well CasingJAN <br /> WELL CONSTRUCTION SANd <br /> Drilling Method$'Mud Rotary ❑Air Rotary ❑Auger D Cable Tool ❑Push Point ❑ Other D U�C�1_ <br /> Proposed Well Depth �dv ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravelll"L Size EPZa� eter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter U in Thickness/Gauge/ASTM Sched BUD ❑Steel Plastic ❑Stainlessst Steel 0 Other <br /> Grout Seal Deptn— ft ❑Neat Cement(94 Ib bag/5-10 gal water) -Ij.,6and Cement�V- sack m1x17 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By At:Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible❑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 /> MINJIMOM 48 H UR ADVANCE NOTICE REQUIRED FOR <br /> �i INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED �ZL� TITLE lJGu 'IL DATE <br /> V <br /> U <br /> i <br /> G <br /> c , , <br /> EPARTMENT US ONLY <br /> Application Accepted By ae Date z /ZOZ Area Employee ID# <br /> Grout Inspection By k M P Date 't1nk O Well Permit <br /> Pump Inspection By. Date ❑ WAIVER Received <br /> Soil Boring Inspedio By Date Constructed Well Depth ft <br /> COMMENTS (?t cf tm'T�—� �) i 1�1 S-P it U;1 P <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Ry") —ra—s.F, Remitted Service Request# <br /> Ldth 9 <br /> 1 0 (P <br /> •2 D <br /> EHD 43-06 6/1112019 WELL/PUMP PERMIT <br />