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1 � <br /> 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.S gov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED f� <br /> Joe ADDRESSU�Lp O I', l r CITY21 r�li <br /> 1 <br /> CROSS STREET S• __APNPARCEL S12E oy LAND USE <br /> /A�PPPLL,ItICATION# _�.�fc��y�...��f_, o <br /> OWNER NAME _._ t� PHO'NnEfyI--Y�rp1�C K(jO-14 r/U—L{' I <br /> ONMER ADDRESS � C I / ' W CV T CITYISTATEZP 1�IA I 1 1iC/`N '�fA(l�1 Ja1% <br /> CONTRACTOR LJ r4,&+`�/L \` If jX i 1[I r�x T PHON�_ 1 Ill1I, <br /> CONTRACTOR ADDRESS r v X. 144//tyto CrrYISTATE21P-.kj %-., <br /> SUBCONTRACTOR/CONSULTANT r, PHONE <br /> SUBCONTRACTT[O_RICONSULTANT ADDRESS Crrr S7A IZJP <br /> LICENSE �-57 C-61 D-09 Other NuMar:REXPIRATION DAT <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPUNG: General Mineral/Coliform Bacteria(4391)kDibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ADomestictPrivate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If Clearer from Owner: Water Syatem Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well AJteration/Modification Other <br /> Monitoring Wells) #of wells Soft Bonng(s) r or borings Geotechnical 11 of borings <br /> Out-aSennce Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Re lacers t Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rota Air Rotary Auge Cable Tool Push Point Other <br /> Proposed Well Depth It Excavation fI in diameter O ttum /C Gravel Pack/Gravel Size in diameter <br /> Condu asing in diameter / Conductor Casing De <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad Steel x Plastic Stainless Steel Other <br /> Grout Seal ���Depth it Neat Cement(94 Ib hag/5-f0 ga!water) Sand Cement sack mixr7 gal water <br /> /// <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant I Accelerator(name) <br /> sTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length It Thick in Christy Box Stove Pipe <br /> )Pu IP Submersible Turbine Other HP Pump Set 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 COMPENSAT N LAWS. <br /> MINIMU 48 A NC E REQUIRED FOR III PLEASE CALL(19b3 76� <br /> SED TILE �J� ` I"(/►' DATE�I,�� <br /> IGN <br /> 1� Air <br /> AQUIN <br /> /4tl 0� �q Nry <br /> DEPARTMENT USE NL)Y ./ �� PirtPiT <br /> Application Accepted By `� Date 7 Area �C/ Employee ID# IllsGrout Inspection By ,SLS _ Date L SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth R <br /> COMMENTS Pj —j*AM 1j- W'I IN norPCAp� [?�fl <br /> PE sC Received ec Amount Dat Parm Invoice# Well ID# <br /> Codes Info av ash Remitted Service Ra uest• <br /> I Vo b <br /> r <br /> EHD 63-06 6/11/2019 WELL/PUMP PERMIT <br />