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% <br /> WELLIPUMP 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.orgl/ehd EXPIRES 1 YEAR FRoM DATE ISSUED <br /> 15 "Joe ADDRESS,y. h CITYIZP :) n <br /> i71y11.\ , APN < < 3iti'�f!BSIND <br /> CROSS ~t h 1.+ .- PARCEL SIZE USE APPLICATION# <br /> ( STREE (Jhc.).C':] <br /> N w <br /> TOWNER NAME -.� _:1%ice U,,,. �•wLl— <br /> �-PHON EL��l{"'SA T.'�� m <br /> :Abu <br /> TOWNER ADDRESS e f,, Siff-� 3 :,.- CITYISTATERIP l /tQ y� <br /> 'CONTRACTOR ` C :LCs� I��, ,�+7``` - PHONE .V-1'^ 8 35 - ,-m <br /> CONTRACTOR ADDRESS q j jz& N. {�TCt I•At' ly,i Y Y _ cnY/sTAlEl7JP_-�OLLl4 _A <br /> r <br /> SUBCONTRACTORICONSULTANT __ PHONE <br /> I <br /> SUBCONTRACTORICONSULTANT ADDRESS CITYISTATEIZIP <br /> � U 2 <br /> LICENSE OC-57 OC-61-61 ❑D-09 ❑Olhe( NUMBER �* XP <br /> � O EXPIRATION DATE (I <br /> BILLING PARTY: Q)WNER ONTRACTOR OSUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:CGeneral MineraVColiform Bacteria(439 1)mibromochloropropane(4392)04rsenic(4393) <br /> INTENDED USE l�omestic/Private 0trigation/Agricultural E�ndustrial L-Water Quality Monitoring LJSW SamplinglCharacterization <br /> 01ubfic Water System <br /> If aifkrent hom Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK C3New Well EIReplacement Well CDWeli Alteration/Modification Omer <br /> 0 Monitoring We➢(s) #of wells C15oll 80ring(S) a orbortno L—]Geotechnical u°f owins. 1 e e a )A.2 0 SCI m p11Y�} <br /> IDOut-OfService Well 0Dut-Of-service Weil Renewal oCross-Connection Repair J <br /> 3Xtew,Pump OJPump Replacement CIPum R lse air 02aWell Casing <br /> 1Ze4d <br /> (WELL CONSTRUCTION <br /> Drilling Method OutudRotary E34irRotary CI4uger Fable Tool E]PushPoint ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom C lGravel Pack/Gravel Size in diameter <br /> OlConduntor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad oSteel OPlastic OShainless Steel (]Other <br /> Grout Seal Depth ft E Neat Cement(94 ib bagl5-10 gal nater) QSand Cement sack mix17 gal water <br /> CBentonite(20%solids) GOther <br /> Grout Placement Method EPumped EFree Fall 001her ElRetardant I Accelerator(name) <br /> PED TAL Installed By DDriller ❑Pump Contractor CI Other <br /> Concrete Pedestal dimensions:Width ft Length ft Thick in hristy Box C75tove Pipe <br /> PUMP ubmersibleQTuNine EbtherHP 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 /> JOAQU7pw <br /> ES, STA E LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURREAND THE LIFORNIA COM TORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKEWS iA?`� E REQUIRED FOR INSPECTIONS-PLLEASE CA" (2179)SIGNED TtrtE �2C( )� V DATE <br /> � MENT <br /> � 2 4 2019 <br /> � �pUNN <br /> Pp�IN ENTAD <br /> - H pEPT-TF,LF <br /> ARTNi�NS <br /> I <br /> AR MENT U�IE O LY <br /> Application Accepted By O i2i!� Area Employee ID# <br /> Grout Inspection By Date 1 ` El PECIAL Weli Permit <br /> Pump Inspection By '(faTU.`,S:A VFtWr"r+1iti Date 21Y11'10tit ED WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth H <br /> COMMENTS <br /> PE SC Receiveq I VChkill Amount Permly Invoice# Well ID# <br /> Codes Info A EIV A Cash emitted Service R uest# <br />