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• Y <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.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS & 21 .1 CITY/ZIP m <br /> �>�a o <br /> CROSS STREET '"�/"7 APN 7Z C' PARCEL SIZE2- LAND USE APPLICATION# O <br /> c✓�� _J�Jd �y ��� Nm <br /> 61OWNER NAME AI'A - /0 PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP/'�� i—,Zi-' e?,*CONTRACTOR am4 . <br /> PHONE <br /> CONTRACTOR ADDRESS �! l�t/,f��� CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT ."1`A// 2r 71'e <br /> NEEr�7 y,��I�SUBCONTRACTOR/CONSULTANT ADDRESS CITY/$TATE/ZIP a� O `- / 1 <br /> LICENSE A/C-57 Atm-61 ❑ D-09 ❑ Other NUMBER^Wk� EXPIRATION DATE",$/3 <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORKNew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ElSoil Boring(s) #of borings iiGeotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRU TION <br /> Drilling Method,)6vlud Rotary Ll <br /> LlAir Rotary El Auger ❑ Cable Tool ❑ Push Point L1 Other <br /> Proposed Well Depth 24" r• ft Excavation IL in diameter ❑ Open Bottom 44,ravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_4� .� Li Thickness/Gauge/ASTM Sched 4471 Steel VPlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ftff� ft ❑ Neat Cement(94 Ib bag15-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout PlacerridInt Method umped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller IV,ump Contractor .❑ Other <br /> n Concrete Pedestal❑ Imensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP 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 COMPENSATION LAWS. <br /> MINI {JJJ�'_U �yam"/J�f�JNCE NOTICE REQUIRED FOR <br /> /I�yNPPE.C✓1TII�O�NS -PLEASE CALL(209) 95,)-7997 <br /> SIGNED ^� ''u / ,L'`' TITLE G 'L� DATE z <br /> 1 <br /> SAN <br /> J A UI O NTY <br /> N (IRON AETL <br /> EW M)M'AF TN NT <br /> i <br /> DEPARTMENT USE ONLY *qg <br /> f1 uI�/ 7Cl <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By li DateI�1� LZ SPECIAL Well Permit <br /> Pump Inspection By Date Z� I-�A"`�'L.y WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS lye, k i,., i C'4 <br /> �..eor,i vl w. 7w <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Eky 1 Cas Remitted Service Request# <br /> 41,3��, i�� yz q 20 21 H25I <br /> C,_s / 1s 2 H25 <br /> y3�7/ iso 2C3 <br /> EHD43-D6 6/11/2019 WELL/PUMP PERMIT <br />