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gr i +�WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP RTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT sjgov.org/ehd EXPIR �Sr� I YEAR FROM DATE ISSUED <br /> LO <br /> JOB ADDRESS 13 oO lki CITY/ZIP CA±' ✓ m <br /> 1 D <br /> CROSS STREET If J (�ALPN 00-7 <br /> 0:70 39 PARCEL SIZE f LANDUSE APPLICATIONS# o <br /> OWNER NAME PHONE -�` rcni� <br /> OWNER ADDRESS J "ma y�''� CITY/STATE/ZIP <br /> CONTRACTOR f�/c a� Oki , ltd , PHONNE3'3 42 i. <br /> CONTRACTOR ADDRESS •L/ff�v /0,0/ 17,9 CITY/STATE/ZIPZlic/aap/33h> <br /> SUBCONTRACTOR/CONSULTANT t/ d f PHONE ✓ ` J! <br /> SUBCONTRACTTOORICONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE 'D -57 ❑ C-61 ❑ D-09 ❑ Other NUMBER.3?7,3t EXPIRATION DATE <br /> BILLING PARTY: ❑OWNER V NTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:AGeneral Mineral/Coliform Bacteria(4391)A Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE 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 New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUC ION <br /> Drilling Method)Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point Ll Other <br /> Proposed Well Depth'?,OCI, l�ft Excavation � [� in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Wet[Casing Diameter AL in Thickness/Gauge/ASTM Sched 2W 11Steel E�Kastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth _ft ❑ Neat Cement(94/b bag/5-10 gal water) V Sand Cement 10 sack mix17 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 I&ubmersible❑ 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 /> MINIMUM 48 HOU DVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 953-7697 <br /> SIGNEDu� /!� TITLE DATE <br /> C_ <br /> ENVIRONME NTNIL <br /> T <br /> DEPARTMENT USE ONLY <br /> Application Accepted By CJL� Date 10 --71—d Area Employee ID# FR <br /> Grout Inspection By ('�LDate '�I ZZ2C'2_ ❑ SPECIAL Well Permit <br /> Pump Inspection By Lr1 f S 1. Date q—k,1-ma, ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE jInfo <br /> Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes B Cash Remitted Service Re uest# <br /> � "3ga6 is-a �0 00 uL13CC L 9 -1- 11 <br /> L13el 4 1SO (01 2I 1�-OD LA/Z-knI <br /> L13c 1 7 a 110 - -) if Do L 'L W2 <br /> EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />