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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 /> QN <br /> JOB ADDRESS �U � CITY/ZIP m <br /> '1 T7�� ] D <br /> CROSS STREET APN I /G /� p( VR PARCEL SIZE P'>>I LAND USE APPLICATION# o <br /> ] m <br /> J m <br /> OWNER NAME <br /> PHO <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR / PHONE <br /> CONTRACTOR ADDRESS !� CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT <br /> SUBCONTRACTOR/CONSULTANT ADDRESS ITY STATE Z P <br /> LICENSEC-57 C-61 _ D-09 _ Other NUMBER EXPIRATION DATE <br /> BILLING PA TY: OWNER _CONTRACTOR _ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USEomestic/Private I_ Irrigation/Agricultural _ Industrial -- Water Quality Monitoring _ Soil Sampling/Characterization <br /> pIr— <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK _ New Well _ Replacement Well _ Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells _ Soil Boring(s) #of borings Geotechnical #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 CONSTRUCTION <br /> Drilling Method _ Mud Rotary Air Rotary _ Auger _. Cable Tool _ Push Point Other <br /> Proposed Well Depth ft Excavation in diameter _ Open Bottom _ Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal wafer) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method _ Pumped _ Free Fall _ Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal _Dimensions:Width ft Length ft Thick in Christy Box _ Stove Pipe <br /> PUMP Submersible Turbine _ Other HP Pump Set S- ft Standing Water Level ft <br /> 1 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 /> MI 8 DVANCE NOTICE REQUIRED FOR <br /> INSPECTIONS -PLEASE CALL (209/) 953-76 7 <br /> SIGNED `%��//�?i— TITLE l/`%�/i'!�/�- DATE L 7 <br /> �r <br /> 0 <br /> ti i i <br /> H <br /> M <br /> DEPARTMENT USE ONLY r <br /> Application Accepted By �� Z LZ Date �81•�l Area I v/ Employee ID# F R. <br /> GroutInspection By Date _ SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Const ucted Well Depth ft Q <br /> CO ENTS �� <br /> ,�jml <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Remitted j%vice Re ues # <br /> 3$► Deo 7 - <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />