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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-REFUNDAB E PERMIT www.sjgov.org/ehd \r EXPI ES EAR (/'m DATE ISSUED <br /> JOB ADDRESS —`/ CITY `J r 0 J " <br /> • p <br /> CROSS STR Cr'e- APN a a 7 3 6 l PARCEL SIZE -9? LAND USE APPLICATION# p <br /> _ L _ m <br /> OWNER NAM r, .,` - L+' L-- �• PHONE /� rA <br /> OWNER ADDRESS v o -7 CITY ST / ✓ <br /> CONTRACTOR )✓� •' C- U .� <br /> TC PHON�� <br /> CONTRACTOR ADDRESS �/" / � , i / �� <br /> SUBCONTRACTOR/CONSULTANT Vff <br /> PH <br /> SUBCONTRACTOR/CONSU/L/T/�_NT ADDRESS ITYISTATEZP <br /> LICENSE C-57 L:-61 D-09 Othe I NUMBEPI EXPIRATION D Tf <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC W L AMPLING: General Mineral/Coliform Bacteria(4391) 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 O—r. Water System Name Contact Name or Phone Number <br /> TYPE OF WORE ,New Well Replacement Well Well Alteration/Modification Other l Y <br /> Monitoring Well(s) #of wells Soil Boring(s) a of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> 'New Pump )(Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION �^ <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other C� <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter _ <br /> Conductor Casing in diameter / Conductor Casing Depth lt <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth It Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mixt]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 Othe <br /> Concrete Pedestal Dimensions:Width ft L n h ft Thick in Christy Box S ve Pipe <br /> PUMP Submersible Turbine Other HP Pump Set It Standing Water Level ft 1 <br /> I TIF <br /> HEREBY C Y THAT I HAVE PREPARED THIS <br /> LICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE NTH SAN LV <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, RULES AND REGULATIONS. 1 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 /> 2ED <br /> E MPENSATION LA <br /> UM 48 HO NOTICE REQUIRED FCp�p(,/,INSSIPEEC�TIIONS-PLEASE CALL(209) 7697 <br /> TIT .!�, • Y ,tel J],Cj/Y L� DATE 1713 1 1­7 <br /> I be <br /> U' Rq yMF <br /> FCFjv�T <br /> N 13? O <br /> 0 <br /> Ro/ Co�? <br /> / DEPARTMENT USE ONLYD�p�R M�NTy <br /> Application Accepted By Cy� Date �S Area Z% Employeeo# AG <br /> Grout Inspection By Date ,1/ SPECIAL Well Permit <br /> Pump Inspection B Date �[/5 WAIVER Received <br /> Soil Boring Inspection By _ Date Constructed Well Depth ft <br /> COMMENTS. Caller (,6yIIf nd e1. V' • I <br /> W we I I. e Set rAf Q1?i <br /> PE SC Received ZheSW Amount Permit <br /> Codes Info Remitted Date Service Request# Invoice# Well ID# <br /> 4 o Z 4 4a t�IN� <br /> r EHD 4346 6111/2019 WELL/PUMP PERMIT <br />