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MW <br />1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 6232 (209) 468-3420 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTELL/PUMP PERMIT <br />NON-REFUNDABLE PERMIT <br />WWW.SOY.O <br />JOB ADDRESS br r /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />- ' <br />CITYZP L. <br />CROSS STREEII-�? m <br />APN _- ( IG- PARCEL SIZE <br />U <br />Q LAND USE APPLICATION # <br />OWNER NAME o <br />'7 �+ PHONE Z01 - 3N- 41(/UV V y <br />OWNER ADDRESS 4 l 75 (� . Q <br />CITY/$TATEZP-&AMpd C-4 4SdolD <br />(CONTRACTOR <br />PHONE q 51 <br />3 a <br />CONTRACTOR ADDRESS 2 W U <br />CITY/STATEZP_y fn1�/V � <br />g �S- <br />SUBCONTRACTOR/CONSULTANT VIA J <br />PHONE_ IA <br />SUSCONTRACTORICONSULTANT ADDRESS <br />CITY/STATEZP_. <br />LICENSE <br />X C-57 C-61 D-09 j Other <br />NUMBER 4{oS8 J (o EXPIRATION DATE Z. <br />BILLING PARTY: _. QwNER <br />CONTRACTOR ", SUBCONTRACTOR/CONSULTANT <br />DOMESnC WELL SAMPLING: _, General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) _ Arsenic (4393) <br />INTENDED UsEDomeslidPrivate _ Irrigation/Agricultural <br />Public Water System - Iii -trial Water Quality Monitoring t $Oil Sampling/Characterization <br />U different from owner. Water System Name <br />-1-11- m- or Phone Number <br />TYPE OF WORK - New Well Replacement Well Well Alteration/Modification <br />Other <br />Monitoring Well(s) # Of wells Sail Borings) # or borings <br />Oul-Of-Service Well - GeolechniCal # of borings <br />Out -Of -Service Well Renewal _. Cross-ConneGion Repair <br />- New PnSeal <br />m Pum Replacement C Pum Re air <br />cnoN -Raise Well Casin <br />d _ Mud Rotary Air Rotary - Auger Cable Tool Push Point Other <br />Depth ft Excavation <br />n diameter Open Bottom Gravel Pack/Gravel Size <br />Conductor Casing n diameter / Conductor Casing Depth ft n diameter <br />Diameter _ in Thickness/Gauge/ASTM Sched <br />De th Steel _Plastic -Stainless Steel Other <br />Depth It Neat Cement (94 Ib bag/5-10 gal water) Sand Cement <br />_. Bentonite (2096 solids) _ Other sack mix/7 gal water <br />Grout Placement Method - Pumped Free Fall Other <br />_ Retardant/Accelerator (name) <br />PEDESTAL Installed By Driller _ Pump Contractor -- Other <br />Concrete Pedestal -Dimensions: Width It Length R Thick <br />in _Christy Box _ Stove Pipe <br />PLIAIP - Submersible _ Turbine _ Other Hp <br />Pump Se( 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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS CO PENSATION L WS <br />h!1 H ANCE NOTICE REQUIP,ED FOR INSPECTIONS - PLEASE CALL (209) <br />SIGNED- <br />>!I ' TITLE �J�Z//G�DATE <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring I pection By <br />COMMENTS j! (,t L v � <br />=HD a7-05 61112019 <br />MENT JIS O LY) <br />Date Z�Ili <br />Date <br />Date ?�%1l7 <br />Area Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />WELL 1PUmP PERMIT <br />y�'ENr <br />