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WELL/PUMP PERMIT <br /> SAM dO QUE Comm EMSEompar L HEALTH DEPARTMENr 1 SBS EAST HAzELTON AVENUE-STOCIUVN CA 95205 6232(209)468.3420 <br /> MON-REFurrpASLE WWW uv.o ehd EXPIRES 1 YEAR DATE ISSUED <br /> JOB ADoaESS (B/ ���i - /�IOA'L IG P!r`..l e—`- cm2m O /¢ 't >6 I <br /> V / 038 STREET*+t C i�xc t/ APINEL S¢E LAND USE APPLM.11 1� <br /> �✓ o� OwNER NAME �4r_ al' 7x o�'nt�n b I 1 t / PRONE If 2;;Ir14 <br /> owNER ADDRE59 �`' e T CITINTATE/ZIP n fGA/�7/sfl/moi . <br /> CONTRACTOR ��aa/�r� /7 s`so�ihtttr �A.i-A/c PHONE !6 7�j77C/+-71�f'3 ext A <br /> CONTRACTOR ADDRESS! 40 c f al b; OF Y AT..,A, -&,v <br /> BIIBCONTRACTOR/CONSULTANT CD'L X L��'// PHONE(9111)Tt I—r8��9/8� <br /> SUBCONTRACTOR/CONSULTANTADORES6 I {M/BTAT!/8P([[Jt <br /> LICENSE W6(O� D-07 0"1 D DD Other NUMBER + EXM"T,ON DATE 7/31/l Oto <br /> MLUNG PARTY; D OWNER 0 CONTRACTOR <br /> DoMmm WELLSAMaINo:❑General MinerBVCollfam Baemda(4391)0 Dibromochloropropaine(4392)0 Arsenic(4893) <br /> UMOM USE ❑DomesbdPrivate ❑imil tionAgeWnaal 0 Industrial 0 Water quality Monitoring Soil Sampting/Charactertzetlon <br /> ❑PWater System <br /> S diff <br /> axtenm rrom ow„rP wall,tinlem wm, ca-W Ness a Pl,m.Nunwr <br /> TYPE OF Wewt D NOW Well 0 Replacement Wel 0 Well Alteration/Modilcetlon 0 Other <br /> 0 Monitoring Wells) _ #of wells 0 SdIBOring(s) Yerbdnrgl Aeoteehnical_ gt - <br /> 0 Out-c"en9oe we" O Out-X-Service Well Renewal 0 Cross-Connection Repair <br /> D New Pump D Pump Reptacemerd O Pump Repair _ ❑Raise Well Casln� <br /> WELL ONSTRUCTION' / _._ .. <br /> Drilling Method t��W Rotary U Air Rotary Nf Auger 0 Cable Tool 0 Push Point D Other__ <br /> Proposed Well Depth/S'--F0 R Excavation 11-4" in dirameter ❑Open BCSom ❑Gravel Pack/Gravei Sizer M dlameter <br /> D Conductor Casing In diameter / Conductor Casing Depth _ft <br /> Well Casing Diameter_In Thickness/Gauge/ASTM Schad 0 Steel 0 Plastic 0 Stdriess Steel 0 Other _ <br /> Grout Seal Depth/S' xD R Aeat Cement(94 Ib bag/5-10 gal water) 0 Send Cement__ sock mbr/7 gal water <br /> D Bentonite 0%solids) D Other__ <br /> Grout Placamerrt MNhod Pumped Xse Fall U Other 0 Retardant/Accelerator(name) <br /> bwWled By 0 Driller D Pump Contractor ❑ Other <br /> 0 Concrete Pedestal ODIm NnxIons:Width ft Len it Thick In O Chdsty Baur O aleee <br /> IP-P D Sutm ershble0 Turbine 0 Other HP Pump Set ft Standing Watar 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IB <br /> CURRENT AND ACTIVE WITH THE CAUFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MII�JIIM•U/M 48 H),r�LU!yp(�ADD CE NOTICE REQUIRED FOR INSPUTIONS-PLEASE CALL(209)953-7697 /Q <br /> FIONED lJt/�7 6^�`'1�Va•" TiTLe I �i r <br /> I <br /> `�[ Jill 1111111IT1111111111111111 <br /> ,V <br /> 41(1 <br /> J0 2019 <br /> f <br /> NVjgQVIN <br /> +H 1cTy 1)pM ��N1Y <br /> --I I 4flil <br /> FNT <br /> I <br /> CA TMENT U O LY ,7F7��r/1 <br /> Application Accepted By Area �� Employee ID#hr✓s`— <br /> Grout Inspection By Date n�AL 111.11 Permit <br /> Pump Inspection By ADate 0 WAVER Received <br /> Soil Boring inspection By Constructed Well Depth h <br /> COMMENTS <br /> PE SC Received Chao Amount Pemlitl <br /> Into ttsd Diets/ Sam*.Reque.1111 Involve0 Well <br /> IM43-a entasia <br /> WELL IRSPPERAaT <br />