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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 <br />www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS���/ <br />CITY0P !? � P <br />CROSS STREET � P. &LR,yJ <br />APN d d O 070"t PARCEL SIZE 4(0 q LAND USE APPLICATION # <br />OWNER NAMES �.�IA <br />t/ PHONE <br />! <br />OWNER ADDRESS (/' t1C <br />/ CITY/STATEZP <br />CONTRACTOR <br />i� 'S PHONE <br />CONTRACTOR ADDRESS <br />CITYISTATE/ZP� <br />SUBCONTRACTORICONSULTANT <br />PHONE <br />SUBCONTRACTORICONSULTANT ADDRESS <br />CITY/STATE/ZIP <br />LICENSE C-57 C-61 D-09 <br />Other NUMBER EXPIRATION DATE <br />BILLING PARTY: OWNER <br />CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE Domestic/Private Inigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System -7 <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 Borings) a of bfxings Geotechnical # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pumo ReolacementR PUMD Repair Raise Well Casino <br />m <br />g <br />1 - <br />kA kA <br />01 <br />1 <br />0 <br />P <br />"I=LL l.UN5I KUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth R Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mix/•/ gal water <br />Bentonite (20% solids) Other S' <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) (� <br />PEDESTAL Installed By Driller Pump Contractor Other }l <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe Y <br />PUMP P15mersible rbine Other HP Pump Set ft Standing Water Level ft I <br />S <br />I HEREBY CERTI 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN V / <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS t <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL U <br />Application Accepted By,---; F -e! L Date S 7 .Z Area S % Employee ID# A6 <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection B Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS ��unjent nuimrdEAn �S b� %,.ie I1�:q GO- i:.oCrEQ�:mob=� <br />PE 5C Received hec Amount Date Permit/Invoice # Well ID# <br />Codes Info as Remitted Service Re e t # <br />1 b SO <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />