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'* pnAL'— Oar : <br /> WELL/PUMP PERMIT <br /> c SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL <br /> P.D. y� CALL,1209 953-769977 FOR INSPECTIONS EXPIRES M1 YEAR <br /> FROM DATE ISSUED <br /> JOBADDRESS Atug l{.AN • .. rfwo Uju w) !�• CITY/ZIP M4Nr*G'T 1 337 N <br /> � A m <br /> Q <br /> CROSSSTREET L)"lop W• APN ��� 60 1• D <br /> PARCEL SIZE LAND USE APPLICATION# v <br /> '1 7-001 <br /> � <br /> OWNER NAME 191 AFI L•ry��[ 'Z NJ <br /> ?A/LT NJ L�.L PHONE 7-00G 1 <br /> OWNER ADDRESS O• •' Ip� J ��►r �j CI <br /> rTY/STATE/ZIP MA�TC'�L,�` 6J4 /�J`.fJ�c ro, <br /> CONTRACTOR M,opii L,aril- _"LU rr `^-s��� .l�u� //PHONE '?I it—(033- 557 <br /> CONTRACTOR ADDRESS <br /> •• 99/ N. CEmI � +�•. CITY/STATE/ZIP "AAN4 cQ r Z it <br /> 1-4 <br /> SUBCONTRACTOR W 4rLLAL0, r f VHL t Ifs���� � PHONE C)/&--??2-/V y <br /> SUBCONTRACTOR ADDRESS 306tfl N�v STI?!p!. ITL Vj>- CITY/STATE/ZIP jje,T^L 0'b#UEA-11-bt C <br /> 9sAc <br /> LICENSE 57 C-61 D-09 Other NUMBER 549 45l EXPIRATION DATE z/ <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(439 1) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring oil Sampling/Characterization <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 Zol"Pr <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical a of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal i Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well CasingV ' <br /> WELL CONSTRUCTION C <br /> Drilling Method Mud Rotary Air Rotary I Auger i Cable Tool i Push Point the, Pt S k <br /> Proposed Well Depth 5b it Excavation Z it in diameter Open Bottom i Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thicknes3/,Gauge/ASTM Schad Steel Plastic I Stainless Steel Other <br /> Grout Seal Depth607 ft ^Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method umped Free Fall XOthe, Tom' ( Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor I Other <br /> Concrete Pedestal i Dimensions: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 /> jjU <br /> 8 HQ1JR ADV E NOTICE REQUIRED FOR IN�SjP/E:CTrIONS_-PLEASF_C L(209)953-76997 <br /> SIGNETITLE �"� ! DATE <br /> ]PAYMENT <br /> CEIVED <br /> 01 19 2019 <br /> 14 fLI 6k <br /> AQUIN COUNTY <br /> ENVRONMENTAL <br /> DEPARTMENT <br /> PA <br /> ENT U�Y <br /> • / <br /> Application Accepted By ate L Area Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By 97 Date 1-2� Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Permit/ <br /> Codes Info Bm Cash erWtted D to Service Request# Invoice# Well ID# <br /> 5 Wr <br /> h <br /> EHD 43-06 revised 4/14/ / / �] WELL/PUMP PERMIT <br /> i-'NI 7 �' (� <br />