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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 /> MWJOB ADDRESS l CRY/LP C m <br /> �y � �j D <br /> CROSS STREET . ✓� ` APN2C4t-110��4 ` PARCEL SIZE 1.L�LANO USE PPLICAATION# <br /> OWNER NAME �^�1,X}^4 I�MtL^1`C. l ��„ 1(C�fi TrPHONE 2 <br /> -O <br /> —I <br /> OWNER ADDRESS x} { Q _„ IV�tw ��� l/J�• CRY/STATEIZIP l 1 O\CV•SIT GI�y J l <br /> CONTRACTOR 11 ^ `� `� PHONE �_Ock J—1 <br /> CONTRACTOR ADDRESS `� LA CRYISTATE/ZIP mo d e 5420 C flir 9 5356 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE 57 C-61 D-09 Other NUMBER 29 D R►3 EXPIRATION DATE <br /> BILLING PAR Y: OWNER CONTRACTOR ❑ SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELLS LING: General Mineral/Coliform Bacteria(4391)CI Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE omestic/Private trrigation/Agricultural Industrial i Water Quality Monitoring Soil Sampiing/Characterization <br /> Public Water System <br /> If different from Owner'. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK xNew Well Replacement Well D Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells ❑Soil Bonng(s) #of borings Geotechnical #of borings <br /> I i Out-Of-Service Well ❑Out-Of-Service Well Renewal Cross-Connection Repair <br /> LNew Pump Pump RpMpMent ❑Pump Repair Raise Well Casing <br /> WELL CONSTW <br /> i 2 /y— <br /> Drilling Method f ud Rotary— I Air Rotary i Auger Cable Tool Push Point Other / <br /> Proposed Well Depth Excavation�in diameter Open Bottom Gravel Pack/Gravel Size Ne l_ in diameter <br /> Conductor acing in diameter i Conductor Casing Depth ft <br /> Well Casing Diameter fn h' es,/ g /ASTM Sched'S .I Steel Plastic Stainless Steel Other <br /> Grout Seal Dspth ement(94/b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> "/ :.ntonite 20%soli s er <br /> Grout Placement Method umped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ump Contractor Other <br /> rl Concrete Pedestal Dimensions:Width ft Length it Thick in Christy Box Stove Pipe <br /> PUMP L Submersible❑Turbine Other HP Pump Set It 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 /> 9 HOUR ADVANCE NOTICE REQRED F R 1 EC N -PLEASE CALL(209)9953-76997 �J <br /> SIGNED TITLE • DATE CJ 1 V fr I <br /> Al(MENT <br /> ECEIVE® <br /> UG 1 9 2021 <br /> JOAQUIN COUNTY <br /> IRONMENTAL <br /> HFJLTH DEPARTMENT <br /> PA TMENT U E JONLY <br /> Application Accepted By`' ,!(i / Date �I �� Area `' ` Employee ID#� <br /> Grout Inspection By Date 1 Z Z SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date onstructed Well Depth ft <br /> OMMENTS 4_ C. / 7-n <br /> PE SC Receive Check#/ Amount Permit/ <br /> Dat Invoice# Well ID# <br /> Codes Ino R mi ed ervice es <br /> .3 $ W <br /> 1, It <br /> EHD4306 6/11/2019 WELL/PUMP PERMIT <br />