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DEPARTMENT <br /> MP PERMIT 1 Ll I' <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)A6$-�aO j �[ U <br /> NON-REFUNDABLE PERMIT CALL 209//953-7697 FOR INSPECTIONS TEXPIRES 1 YEAR <br /> `�FROM DATE ISSUED <br /> JOB ADDRESS �`� SC CRY/ZIP //-ai'�C1Ir / 7 300"61 m <br /> CROSS STREET /jam/ -�-�C��'T (II APN� 0-0 PARCELSIZE LJWDIJSE APPLICATION g o <br /> ` i C7rT GSG� -�ULI-OI a <br /> OWNER NAME l�r'ln ri �I/`�/� / C�.� PHONE r� <br /> OWNER ADDRESS yI - E CITY/STATEIZIP <br /> CONTRACTOR /v Et✓Ily.��( J�1�J�)��y� /�`p PHONE <br /> CONTRACTOR ADDRESS_ VV ) -T U`ly li l.�. ra - V�rI�f CITY/STATE(ZIP �Ct'6�';'r� C_ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP _ <br /> LICENSE _C-511 �161 _ D-09 Other -Z- NUMBER 10.5-zti / <br /> EXPIRATION DATE I!-30- ?' <br /> DOMESTIC WF_LI_SAMPLING:_.General Mineral,(Coliforrn Bacteria(4391)_Dibromochloropropane(4392)-Arsenic(4393) <br /> IxTENDeD UsE _DomesticJPnvate -Irrigation/Agricultural _ Industrial =Water Quality Monitoring Sod Sampling/Characterization <br /> - Public Water System <br /> If different from Owner Water System Name Conrad Nein or Phone Number <br /> TYPE OF WORK n New Well eplacement Well -Well Alteration/Modification Other <br /> G Monitoring Well(s) #of wells Soil Sonng(s) F of bO""9' -Geotechnical x or borings <br /> G -Of-Service Well Out-Of-Service Well Renewal _-Cross-Connecfon Repair <br /> ,Qdew 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 Bohom - Gravel Pack/Gravel Size in diameter <br /> --Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thidmess/Gauge/ASTM Sched -1 Steel -Plastic .-Stainless Steel C Other <br /> Grout Seal Depth ft E Neat Cement(94 Ib bag15-10 gal water) =Sand Cement sack mix17 gat water <br /> Bentonite(20%solids) D Other <br /> (Grout Placement Method __Pumped -.Free Fall -.Other 2 Retardant)Accelerator(name) <br /> PEDESTAL Installed By --Driller ump Contractor Other <br /> Concrete Pedestal---Dimensions Width_ft Length R Thick in -Christy Box Stove Pipe <br /> lawn uhmersible=Turbine Other HP Pump Set ) It 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 CTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERSfUENSATION WS. <br /> ZANCE NOTICE REQUIRED FOR INSPECTION,-PLEASE CALL(209)953-7697 <br /> . <br /> SIGNE - TITLE DATE Ile <br /> 01 <br /> F/ <br /> 2 c,� ,9 <br /> 2019 <br /> I ) T p I FN U <br /> FpgRT��NT <br /> P' TT ETT <br /> MENT US O LY /�,��/� <br /> Application Accepted By ate Area Employee ID#/�k'g T 4 <br /> Grout Inspection By n Date PECIAL WeII Permit <br /> Pump Inspection ByDale_.C�12�� t cr - WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC I Received Check#) Amount a Permit/ Invoice# Well <br /> Codes Info ash R mitted Service Re uest# <br /> EHD G}D6 nrasd atatfi 'JJFLf/PUMP Fc RR11T <br />