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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 /> 57;t—AJ <br /> f I � <br /> JOB ADDRESS D / �"`' CITY/ZIP d/�l/ <br /> Mm <br /> CROSS STREET U`` IS-IctAP PARCEL SIZE LAND USE APPLICATION# o <br /> OWNER NAME /���� d��`-/� /tel J % � <br /> PHONE <br /> rPHONE <br /> OWNER ADDRESS CITY/STATE/ZIP l/�—7 Z4'* <br /> CONTRACTOR //AW111AASfA�� <br /> � <br /> PHONE <br /> �/� <br /> CONTRACTOR ADDRESS l Z�/�!/ y^��-� v�—/� CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT ////77hG��S fy/L-�LL�//��f7 PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE 1 -57 019-61 01D-09 ❑ Other NUMBER / � EXPIRATION DATE 3 Z <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: 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 Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well X Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) *of wells ❑ Soil Boring(s) #of borings r- 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 CONSTRU TION <br /> Drilling Method YMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 80 ft Excavation I-Z-- in diameter ❑ Open Bottom ^ravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter l0 in Thickness/Gauge/ASTM Sched C,4-?� El Steel AI'lastic E-1StainlessSteel Li Other <br /> Grout Seal Depth ZO ft ❑ Neat Cement(94 Ib bag/5-10 gal water) VSand Cement fQ. sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method lypumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller .V1Pump Contractor ❑ Other Or <br /> ❑ Concrete Pedestal []Dimensions:Width_'/ ft Length ft Thick & in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine F1 Other HP Z Pump Set y! 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 /> MINI U/ NCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 953 76%7 <br /> SIGNED TITLE DATE ZD <br /> )I <br /> I TY <br /> INVIRONIAENTfil- <br /> T <br /> DEPARTMENT USE ONLY <br /> Application Accepted By <' Date / Area C� Employee ID# S <br /> Grout Inspection By _ �/L- Date Z/ SPECIAL Well Permit <br /> Pump Inspection By _ Date 3 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS G�vS17�y /vp <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info BCash Remitted Service Request# <br /> 4/1: oma' isz �(2s <br /> 413`'/ %.s 0 Day <br /> y3 2_ 70 W 2 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />