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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 PERM- Q WWW.S Ov.Or /ehd EXPIRES IYEAR FROM DATE ISSUED <br /> JOB ADDRESS �# - T /T I�E/eL LJ CRY21P .7V �T <br /> CROSS STREET �' APN O77-3G&0_NA PARCELSIZE LAND USE APPLICATION# a <br /> OWNER NAME /��s"��y��60—,e,*`,0jA1e IlArZOX r PHO/NEE �/� y� _ o! <br /> OWNER ADDRESS /� B '�a�y,* sr. CITY/STATEZP/A``Aiq M"///V Z <br /> CONTRACTOR `C Se N. A /NC' PI <br /> CONTRACTOR ADDRESS "7'r `y�t/ CITY/STATE/ZIP s0NP40el AV 0 9s37D <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CIT�YYISTATEZP yy <br /> LICENSE xC-57 0 C-61 0 D-09 ❑Other NUMBER ,2S 7 EXPIRATION DATE 7 a QO2 <br /> BILLING PARTY: 0 OWNER CONTRACTOR 0 SU13CONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)D Dibromochioropropane(4392)[aArsenic(4393) <br /> INTENDED USE 0 Domestic/Private rrigafion/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> APAL� 0 Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> .TYPE OF WORK ANew Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> 0 Monitoring Well(s) #of wells 0 Soil Bodng(s) #of boringe 0 Geotechnical #of borings <br /> 0 Out-Of-Service Well ❑Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION ' <br /> Drilling Method j(Mud 5otary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br /> Proposed Well Depth 6111 It Excavation in diameter ❑Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth It <br /> Wall Casing Diameter_in Thickness/Gauge/ASTM Schad 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth d O Q: It 0 Neal Cement(94/b bag/5-90 gat water) ❑Sand Cement sack mixt7 gal water <br /> Bentonite(20%solids) D Other <br /> Grout Placement Method KPumped 0 Free Fall ❑Other ❑Retardant I Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑Pump Contractor ❑ Other <br /> 0 Concrete Pedestal❑Dimensions:Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP 0 Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level It <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. 1 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 COMPENSATION LAWS. <br /> MIN ZM HQVR ADVANCE NOTICE REQUIRED FO SPECTIONS-PLEASE CALL(209)9 3-769,7w <br /> SIGNED TITLE DATE <br /> q�'M <br /> if <br /> I CFS �T <br /> D <br /> t I 1 QU/N COU <br /> f' <br /> F gR7.416V <br /> d <br /> DEPARTMENT USE ONLY /}�f <br /> Application Accepted By .0 Date H �' Area �% Employee ID# r' " <br /> Grout Inspection.By 1^� Date ID 2� ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date / Constructed)Nell Depth ft <br /> COMMENT r_ I>}I)Z' Vdt' o i. .h1N rt)FfS"' I�v� c ,4tgtt:/ .7t7r,I{IT <br /> / c 'f e)I <br /> PE Sc Received Check#/ Amount pat Permit/ Invoice# Well ID# <br /> Codas Info Cash Remittedrvice Re uest# <br /> 3�1 U 0 9M14 2� <br /> EHO 43-06 6/1112019 1z37SPERMITWELL/PUMP PERM <br /> . � <br />