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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.S OV.Or /ehd EXPIRES 1 YY�EAR FROM DATE ISSUED <br /> JOB ADDRESS 133 / s CmIZIP 1 m <br /> a <br /> „ m <br /> CROSS STREET EDDle-VJU < �/ + AAtPN +V-O 1 Vtn'ARRCEL SIZE SIL �D USE APPLICATION# S <br /> OWNER NAME R..4 l I J k,�G� I V•e�I I!r C,.i PHONE y <br /> OWNER ADDRESS y,,.X11- V CITY/STATE21P I <br /> SU$CONTRACTOR `�teyr^6, �??,D ICCA� PHLONE 33 4� t/' p <br /> S CONTRACTOR ADDRESS�/ yI(1� aAbiay CITYISTATEIZIP T).11,',A cV ' Ot l (/��19 <br /> oth}fq( +\ ONSULTANT CseeCAYI�/1�(�� i PHONE f'1 Z J /d 9WT <br /> 2141 <br /> SUBCGMTRxcT=CONSULTANT ADDRESS(06 11 Dr�sCA ! "4" CITY/STATEIZIP �1�� 0�// �r ijils-S V <br /> l-0YV W p1 a <br /> LICENSE )(C-57 -C-61 D-09 -Other NUMBER { L1 EXPIRATION DATE -l <br /> BILLING PARTY: -OWNER -CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)C Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE C Domestic/Private C Irrigation/Agricultural C Industrial -Water Quality Monitoring C Soil Sampling/Characterization <br /> C Public Water System <br /> If different from Owner. Water System Name contact Name or Phone Number <br /> TYPE OF WORK C New Well �: Replacement Well Well Alteration/Modification C Other <br /> CMonitoring Well(s) #of wells =SoilBoring(s) #ofbonngs XGeotechnical_ #of borings <br /> C Out-Of-Service Well -Out-Of-Service Well Renewal --Cross-Connection Repair <br /> C New Pump Pump Replacemen -Pump Repair = Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method C Mud Rotary C Air Rotary Auger -Cable Tool - Push Point - Other <br /> Proposed Well Depth115 ft Excavation in diameter C Open Bottom C.Gravel Pack/Gravel Size in diameter <br /> C Conductor Casing in diameter 1 Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched E Steel C Plastic Stainless Steel ❑Other <br /> Grout Seal Depthft Neat Cement(94 115 bag/5-1al water) Sar"�/Cem t sack mix/7 gal water <br /> u)� I� <br /> C Bentonite(20%solids) --Other C/U l4_"YIMYNLPNC - <br /> Grout Placement Method C Pumped Free Fall =Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By = Driller - Pump Contractor - Other <br /> C Concrete Pedestal Dimensions:Width ft Length ft Thick in -Christy Box -Stove Pipe <br /> PUMP C Submersible--Turbine - Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 AC WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP TION LAWS. <br /> MI U ADVANCE NOTICE REQUIRED / K. <br /> FOR INSPECCTIO,N,S/-PLEASE CALL(209)953-7697 q <br /> SIGNTIT.Tritt1D� 7�N�' G/'lR/•lam/ DATE <br /> E V <br /> cYMENr <br /> o <br /> 3 p 2419 <br /> U/N C0 <br /> r fMF <br /> Al <br /> NT <br /> FN <br /> D,EP,, RTMENT7U E O LY Dal, <br /> Application Accepted By ,VAS/ Date 1G 3O Area Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date _ WAIVER Received <br /> Soil Boring Inspection By i Y Date ) q, 2 Z" Co Structed Well Depth ft / ] <br /> COMMENTS r Q Lp r a i e{ - de, <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Rrgitted Service Request# <br /> LOU puff U, <br /> EHD 4306 611112019 WELLHUMP PERMIT <br />